Mid-sentence I grabbed the Thompson retractor as my body instinctively protected itself from falling as my subconsciousness hit the off button and I fell asleep standing. It was a living donor liver transplant that I had scrubbed into to assist. I quickly brought myself to attention, naively thinking no one had noticed. I was thankfully told to leave the operating room to lay down.
Operating is demanding in many regards. It takes years to train to become a surgeon. Within those years there are many long days, most at least 12 hours, often longer. Those days are spent walking around the byzantine hallways of a hospital, rounding, standing for prolonged periods of a time in one spot with limited access to healthy food or water. All of this is coupled with repeated, constant sleep deprivation, and sleep disruption from pages and other clinical demands. These circumstances are in the best of programs that adhere to the 80-hour resident work week imposed by the ACGME. In transplant surgery fellowship, there are no restrictions on work hours and schedules center around total days off in a month, rather than the actual number of hours worked consecutively.
Falling asleep operating is an experience I think every fellow can relate to. Being hungry beyond the point of wanting to eat. Not having to scrub out to urinate simply because you are oliguric from lack of appropriate hydration. Those are some of the realities from 8 hour or even longer liver transplants, multiple kidney transplants in a row, and then leaving to do a procurement all to repeat it the next day, and the next.
We somehow get through it. We endure. The human body is capable of the demands of surgical training thanks to evolutionary adaptations that protect against dehydration through antidiuretic hormone activation, protect against starvation through gluconeogenesis pathways and fat store mobilization. But is this ideal? Should we be pushing ourselves to this degree? Do high performing marathon runners and other endurance athletes train by intentionally starving themselves, depriving themselves of water and sleep? The intuitive and obvious answer is no. So why do we allow surgical trainees to do it? Why do we not call attention to this and be explicit about the fundamental needs of the human body, to optimize performance and training in the operating room?
Surgery residency, subspecialty fellowships, and then individual longer operations such as transplants, can each be viewed through the lens of a marathon. You do not and cannot simply get off your couch and run 26.2 miles without previous training. Even if you have run shorter
distances, you still cannot do this distance without intentional training, focus and effort. Similarly, you cannot at the start of transplant fellowship independently perform a liver transplant, or a kidney transplant, even though you have operated throughout residency. To get through surgical residency, or any fellowship, there are a few guiding principles I think we as a community ought
to emphasize, akin to training for a marathon (in parentheses).
- Repetition with progressively harder and longer cases (runs)
- Appropriate time for recovery between cases (runs) with time for meals and water
(optimized nutrition) - For longer cases (runs), having food and water available (optimized hydration and
nutritional supplementation) - Sleep
- Ideal surgical ergonomics (strength training/flexibility)
- Optimized equipment including shoes, anti-fatigue mats, lighting, bed height (running
shoes, gear) - Attendings and program directors tracking and optimizing performance, recognizing
when the trainee has pushed it too far and an optimized surgical culture recognizing the
demands placed on trainees (a coach!)
We can change culture. I do not have all the solutions, but the most powerful intervention I think is awareness: spread this blog on social media, talk about surgical endurance with colleagues. If you are a trainee, speak up for yourself. Ask for the table-height to be adjusted, ask to scrub out for a moment for water, work with your program director so that schedules are manageable. As faculty members, we need to lead. We need to recognize the signs of excessive fatigue in trainees and reflect on the points of surgical endurance. We need to encourage breaks, food, water. Make the operating room culture acceptable for trainees to speak up and scrub out if needed. Optimize ergonomics for yourself and trainees. These are all easy interventions that can have an outsized impact on endurance, performance, and overall well-being.
Surgical training is hard, but it can be better and we as a community can change culture. We can optimize performance in trainees with relatively simple interventions, which I think would help with trainee well-being, better surgical outcomes, and the ability to have a long and satisfying career.
William Crannell
Latest posts by William Crannell (see all)
- Surgical Endurance - June 6, 2025
Congratulations to the 2025 AAS/AASF Faculty Awards Winners!