Viejo

The patient is small and sits neatly in the chair. He speaks only Spanish, and he's with his son who is bilingual. The son calls him Viejo- old man. Diagnosed in his thirties, he's had PD for more than thirty years and yet he has no resting tremor. His face has little expression and his speech is gruff but when he walks in the hallway, he still swings his arms. He complains of not being able to sleep for more than three hours at night, rising twice to use the toilet. Yet he has a sleep benefit; he wakes in the morning and he is "on". The dopamine producing cells in his substantia nigra are still producing sufficient neurotransmitter, enabling him to wake and move, not taking his first pills until eight o'clock.

The doctor asks about dyskinesia, and the son confirms he has uncontrollable movements. He's not moving now, no twitches, no tremor. He hold his arms straight out in front of him and the right hand trembles slightly. His lips purse as he concentrates on the outstretched arms. The lips cover his teeth entirely; old man lips, maybe he has lost teeth.

The son doesn't sit. He stands leaning against the wall in the small cubicle with the doctor, the medical student and me. We sit on various objects, mostly stools and chairs. I sit on the lid of the garbage, but there is an open chair for him. He wears a blue cap, which he keeps on as he shifts, leaning with his back to the wall, then turning to face the doctor, one side to the wall. The doctor speaks about physical therapy, asking whether he has Medicare- No, Medicaid the son replies. The doctor advises a call before arriving at therapy, to make sure they take that type of insurance. They are out the door with new scripts and a green file in hand.

The chart gives details of a pallidotomy performed in Cuba. The brain surgery apparently eliminated the tremor from half his body. He must have arrived here not long ago… imagine a patient with PD on a raft of tires in the waves of the Florida Straits. Surely, he couldn't simply have arrived by plane, perhaps with a detour through Mexico. How feasible are Cuban pallidotomies for citizens of the United States?

Medical tourism appears to be flourishing in Cuba, by way of Canada for people with passports from the United States. The Neurological Rehabilitation and Restoration Program treats patients with Parkinson's Disease.