Sixty-four cups of coffee a day

It comes to excess caffeine,

The insomnia, tachycardia scene.

For with cups sixty-four,                                                      

Not less and not more,

We see the toxic side of the bean.

Synopsis:  I’m a family practitioner from Sioux City, Iowa.  I danced back from the brink of burnout in 2010, and, honoring a one-year non-compete clause, went to have adventures and work in out-of-the-way locations.  After jobs in Alaska, New Zealand, Iowa, and Nebraska, I returned home and took up a part-time, 54 hour a week position with a Community Health Center.  I’m just back from a working vacation in Petersburg, Alaska.

I went to breakfast with a couple of other docs.  All three have worked locums and enjoyed it.

Over coffee we discussed caffeine’s medical effects.

One doc told about a patient with a racing heart (tachycardia) and diabetes.  Eventually he stopped the family from bringing in 7 caffeinated sodas a day, and then the patient’s sugars normalized and the heart rate slowed.

The other doctor asked if headache had followed.

I made the observation that I can give anyone a migraine if I give them a high enough dose of coffee for a long enough time and then stop it suddenly.  Then had to tell about the worst caffeine addict I ever took care of.

For the sake of this blog and the patient’s identity, I won’t say where or when I met a fellow in his early sixties with insomnia and a racing heart.  On the first visit he revealed his 64-cup a day caffeine problem.

“Sixty-four cups a day?”  My colleagues asked.

“Yep,” I said.  “I had him taper down a dose a day, stay at a dose for two days if he got a headache.  It took all summer but I got him down to zero, had him stay at zero for two weeks, then rechallenge.  Two days later he was back to 64 cups a day.  He just felt lousy without it.  Clearly, he wasn’t wired like you and me.”

“What was his blood pressure?” one asked.

“Normal to low,” I answered, my memory making a successful leap over a long chasm of years.

“Did he have Addison’s?”

I came to a screeching halt.

Addison’s disease comes from inadequate cortisone production, a failure of the adrenal glands to produce a hormone necessary to maintain blood pressure and salt retention.  The most famous Addisonian patient was JFK, and owed his signature deep tan to the disease.  In the course of the last 30 years I have managed a handful of cases (one found by a really sharp psychiatrist) but diagnosed none.

I had to admit I hadn’t considered the diagnosis at the time but I should have.

Then I had to recall lessons learned from managing blood pressure in a suspect pheochromocytoma (docs shorten it to “pheo”) patient.

This disease involves a tumor of the outer adrenal gland, the part that puts out adrenaline.  We spent lecture after lecture in med school on the subject.  With a case rate of 3 per million, though, primary care doctors can tell when they arrived by the time it takes them to see a case.  It took me 30 years.

We talked about alpha and beta blockade, and a drug only used for this vanishingly rare disease.

But we also talked about negotiating, game theory, decision making with imperfect information, the origin of the Syrian nerve gas, Sarin (probably Iraq), Israel’s precarious position, hospital politics, our respective future plans, and problems with Obamacare.

We didn’t always agree, but when we finished we were better doctors for the colloquium.