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The nurses and scrubs rotate out for lunch and breaks and shift change; CRNAs too. The surgeons usually will stay in the whole time, no food, no drinks, no breaks. But it’s usually rare to have a case last that long, but I’ve seen poly trauma run longer than 12 hours and some big OMFS cases run long too.

Traditionally the scrub techs and nurses are employed by the hospital, and as such are required to have 2 15 breaks and 1 lunch. They have a float person cover for breaks. Nurses give a brief rundown of what stage they are at and any pertinent medical history or charting stuff. Same for the scrub techs who cover breaks.

The doctors are independent contractors and usually work all the way through a long case. Longest was maybe 8 or 12 hours that I’ve seen. If they do need coverage usually their medical group has someone who they can contact to hand it off. Usually not though 99.999% if times

No drinks? Does the surgeon not even get a chance to have someone hold a juice box to their face? Or is that more likely to make them have to unite, which would take them away for longer.

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Uniting urinating is an interesting topic, I can't imagine they can't do without for hours on end, but then again the whole suiting up etc. is time consuming
Would also like to know how they work around it

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They don't excrete. It's not uncommon for surgeons to develop kidney and back issues from operating.

Everyone except for the surgeon gets rotated out.

Usually big long surgeries have 2 surgeons. One is the primary surgeon and the other is assisting. The assisting one may be another attending surgeon or a resident surgeon. Even big surgeries have a point where the patient is stable enough to temporarily pause so one of the surgeons can be relieved for a minute to get some food, use the restroom. So the patient is never without a surgeon, but surgeons don’t operate through a 36 hour case without a break.

Daughter of a spine surgeon here: They DO eat and drink, just not a meal. Nurses give them "bite size snacks", like a piece of chocolate, or some water/juice with a straw. The surgeon does not touch the food, the nurse gives it to them, and this keeps them going till the end of the surgery. However if they know they have a long surgery ahead they will eat and drink well before going to the surgery room. They also DO go to the toilet if they really need to. Even though surgeries do have critical moments in which everybody must be concentrating at 110%, there are also moments that are a bit less "critical", and these are the moments where they can go for a quick pee or take the snack from the nurse (bare in mind there are usually more than 1 surgeon so the other one can keep things stable and safe). They try to hold if they can, and rarely go number 2, but if they have an emergency diarrhoea they must go, simply because it would not be safe for the patient if the surgeon is performing a delicate operation while having massive cramps :/ in those cases is best to just quickly go to the toilet and come back.

But... what about sleep?

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What’s a scrub?

I don't know much about the reality of medical professionals, but from what I understand sleep seems to be one of those "do as I say, not as the structure of my employment has me do" for them.

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This, I don't understand. Surely, anything above even 15+ hours of concentration is counterintuitive, right? Like, what about the loss of focus, accuracy, and drowsiness? Maybe 24 hours is doable since they've had a lot of practice, but 36 hours is insane.

Like, I start going delirious and dissociating from reality at 30 hours mark (without any stimulant drugs), can't imagine a surgeon not tripping balls from the sleeplessness haha.

Scrub nurse

https://www.wgu.edu/blog/surgical-nurse-job-description-career-guide2008.html#:~:text=Scrub%20nurse.,duties%20inside%20the%20surgical%20room.

You pee shortly before going to the OR so you're usually good for a few hours. There's a "first assist" which is usually a resident or PA scrubbed in helping. In long procedures there can be tedious dissecting so the attending can break scrub and go urinate or eat a quick snack while the resident keeps working. Only takes a minute or less to scrub in these days (Avagard replaced the old 4 minute scrubbing, and the scrub tech will have your gown and gloves ready for you) so that's not a barrier at all.

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Head and neck surgeon here. 24h shifts are the norm, it’s something you just get used to. It sucks but that’s the reality of it. 36 hours of nonstop work does happen, especially in residency. It’s definitely taxing and impacts your productivity especially during low stake work like charting. I had instances of my prechart notes being absolute gibberish due to sleep deprivation. But when it comes to procedures your body runs on adrenaline, tired or not it feels like a reset button was pressed, even during longer procedures like laryngectomies. Getting distracted doesn’t really happen unless you are a med student holding the retractor then all you have left is praying for mercy and sweet release

Surgeons take short breaks too. During non critical points in the surgery, the surgeon might step out while the resident continues.

ah, that's amazing, some superheroic stuff. Crazy what the human body and brain can achieve with practice beyond limits. Do you have sugar/caffeine too intermittently during these work hours or is it just adrenaline/chronic stress

We eat and drink coffee during shifts, nothing different compared to an office job. Part of resilience is definitely adaptation though, residency is exploitative. My speciality doesn’t have those 20-ish hour procedures (at least none that would be all-HNS team) so no surgeon rotation, if it’s 4-5h in the OT you’re stuck there for 4-5h. Then again, hunger or sore legs is the last thing you’re concerned with assuming you’re actively participating, even more so if you’re the primary surgeon.

Watched a couple of BBC documentaries on specialty surgeries. Depending on the kind of surgery and if you are lucky enough to have 2 specialists in the same hospital, you miiiight be able to do a handover partway through. In cases where its not possible, you would try and limit the amount of time the specialist is actually working (eg where they let someone else do the "easy" bits and only have the specialist work where needed). But otherwise it seems 12-18 hour operations arent uncommon. Not sure if this is varies by country, but at least the episodes I saw, if it was going to be crazy long they might try and see if its possible to do the surgery in 2 phases to break it up so the surgeon can have a break in between. But thats not always possible obviously.

Head and neck surgeons do orchestrate some of the most complex and difficult surgeries though. You may have several teams doing different parts of a surgery and take turns. I have seen as many as 4 or 5 teams work together. Neurosurgery, ophthalmology, plastics, OMFS and ENT/ HNS all can participate on some large tumor resections and reconstructions. When actively involved you can get so focused that food, pee breaks, etc don't cross your mind for 8 to 12 hours. Then you finish and it all catches up to you.

Yes but as you mentioned for stuff like anterior or lateral approach skull base surgery or large tumor dissections we do take turns. it’s usually a combined effort by neuro, maxfac and ENT. Compare it to stuff like transplantology where one team usually handles the entirety of the procedure.

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The poor dude running the fluoroscopy might have to stay there the whole time. Source: I’m that dude. My personal record is about 9 hours, although I took a couple quick pee breaks. (Busy day so no longer term relief available.)

I’ve also seen a few cases where a partner comes in to relive the attending on particularly long spine cases. I’ve seen a couple 10-12 hour cases. I don’t have personal experience with those legendary 16-24+ hour traumas though.

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Doctors aren’t employed by the hospital they work at?

Sitting on the stool the whole time? Not likely

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To add to what others have said, and to make this more generalizable outside of just medicine...

Swapping out people who have been working a long time for fresh people is limited by two factors:

1. The availability of fresh people. There are often alternate nurses available for a very long case. In some situations there may simply not be another surgeon available. This is part of the responsibility that comes from being in positions of leadership, or having a very specialized knowledge base and skill set. In times of “crises,” you may be working absurdly long hours for a very long time.

2. Transitioning to a fresh team is associated with its own risks. The fresh team will be less familiar with what’s going on, and miscommunications about the situation may occur during the transition. A critical event that happens during the transition may also be disastrous due to unclear individual responsibilities and communication flow.

There have been scientific studies on patient outcomes with physicians working either very long shifts, or shorter shifts but with more “signovers” of care happening. There was no improvement in patient outcomes with shorter working hours, presumably because of the risks that occur due to care transitions.

Balancing the above points is something that must be done in many situations, not just medicine.

How does the military decide when to switch out troops in a war zone?

How should government deal with decision making during a prolonged and intense period of time?

Etc.

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They give them food in the OR itself? As opposed to having a first assist take over while they step out for that quick snack or pee break?

I cannot imagine infection control being cool with that.

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they do, but is not like they would eat cookies which would crumble, but yes. The OR is clean but not completely sterile, what's sterile is the tools, instruments, operating bed and some other things that go in direct contact with the patient. So like a bonbon is not that weird. Plus, they don't feed them while being directly over the patient.

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You mean no benefit to longer hours. That’s how the study should be interpreted

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Nope! Doctors are independent contractors. They also have a right called Refusal to Treat, that nurses don’t have the privileges of either.

Depends. Some are employed by the hospital, some are under contract with the hospital. Usually specialists and surgeons are under contract due to the high skill level and broad need, they will often have their own practice and contract with different hospitals or medical agencies. At least here in the US, this is why your billing following a procedure will come from the hospital and the different practitioners.

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Or just straight up take a break and there’s a pause in surgery. The surgeon needs nourishment and a mental break to do their best surgery and make good decisions. I have seen (and participated in) breaks of 10-15 minutes to go to the bathroom, eat, and let your brain rest a little while the patient is on the table with nobody working

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Multi-level surgeries are a thing. What they are is you have a 15 step 30 hour surgery you need to do. You do steps 1-8 for x hours sew up or cover up, rest for several hours for both the surgeon and the patient, then complete steps 9-15 at a later date.

10-15 hour surgeries are relatively common but 36 hour surgeries are nearly never done all at once unless the patient will die very soon without the surgery and they cannot afford a few hours of rest. Most likely in that situation they would have an extremely high likelihood of death during the surgery so most times these surgeries would never be done and family wishes talks come into play.

Usually traumas get the special service of repeated surgeries with long total operative time with ALSO an extremely high risk of death within the next few hours that would prevent taking breaks. But even then patients can be stabilized long enough to take breaks, breaks for the patient are usually more important than breaks for the surgeon.

Especially in surgical specialties (and especially as a trainee) sleep deprivation is a constant. It’s kind of hazing

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They don't do that. Maybe catch a 15-30min nap at most but surgeons and surgical techs/nurses can work 24-36hrs consecutively without sleeping. They shouldn't, but they can and do.

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IIRC the Navy did a couple studies after a rash of collisions and other ship casualties. The net result was to shorten the shifts in certain critical command/control positions - Officer of the Deck, Navigator, helmsman, Weapons Officer, etc.

The critical factors in all the casualties they investigated was that decision-making abilities and accuracy declined dramatically after a fairly low number of hours where these people were dealing with a state of constant information overload.

The shortened shifts flew in direct opposition to the prevailing “man up and deal with it” culture prevalent for so long. In the end, safety won out.

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Could you explain the difference? Are you familiar with the studies being referenced? I am familiar with how the null hypothesis works, if that helps.

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Wonder how much the surgery death rate and success rate would change if they didn't do this.

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I work in surgery as an x-ray tech. Vascular surgery and cardiac to be exact. There are a total of 8-12 people involved in our cases. X-ray, crna, attending, residents, fellows, research team, reps of the devices, circulating nurse, scrub tech, additional scrub/nurse. The anesthesia team gets breaks since they monitor the patients status non stop. The physicians do not get breaks if alone but some work as a two doc system. They don't leave the resident alone with the fellows. It's a teaching hospital. I work in 4-6 hour surgical cases daily in a level 3 trauma center. We have 46 OR rooms crazy right?

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Unfortunately, we’ve learned that continuity of care is better for patient outcomes in practically all scenarios compared to physician rest. Handovers may occasionally result in loss of information leading to poor outcomes which is just the nature of switching hands.

Main issue I see if you have someone step in they need to know exactly what has happened and what's next. Problem is making sure all the info would be passed. Which is easier to happen that most people think

You might think I was referring to some of the NEJM papers that came out around 2018 comparing standard to “flexible” scheduling?

I was more talking about the older papers that came out in the first decade of the 2000s when duty hour restrictions first came into place... which compared old-school scheduling to duty-hour restrictions and found no difference in patient outcomes (or occasionally worse patient outcomes with restrictions in some of the surgical literature).

You can have nurses scrub in and assist directly with the surgery as the other redditor said.

Also some hospitals will employ surgical technologist “scrub techs” who help the surgeons manage instrumentation and sterile equipment but these techs will not be nurses themselves. The nurses in these cases will just be circulators who document and grab extra supplies and generally keep the room running smoothly.

At my hospital we have several nurses who were originally surg techs and have kept up their credentials. They’ll sub in when needed but we typically have separate scrub techs and circulator nurses.

They're saying that if the two are statistically indistinguishable, "there's no benefit to forcing staff to work long hours" is a 'better' way of phrasing it compared to "there's no benefit to not forcing staff to work long hours". The first implies that being good to your workers should be the default choice; the second the opposite.

"if you see a transplant surgeon, give them a coffee and point them in the right direction"

Which are you speaking of? This metareview basically concludes that limiting working hours is not associated with better outcomes, since the one study they found that said that it did also came with a caveat from the study authors that they believed the improvement to be caused by unrelated factors.

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I'm a CRNA in a mid sized regional medical center. We only trade out up to a certain point. After 8pm if I'm on call I'm the only anesthesia provider in the OR (we have one dedicated to OB but it has to be an all hands on deck emergency to ask them to come down) and so there's no bathroom breaks after that time. Surgeons, scrubs, and circulators can all scrub out and go pee but anesthesia can't leave the patient unattended, ever. Every facility is different and it's super rare for us to do cases longer than 8-9 hrs here but the potential is always there when you work in the OR.

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This reads like someone who isn’t familiar with how physicians are trained.
The number of residency slots is effectively stipulated by the Medicare budget. There are more and more medical school grads who go unmatched to postgraduate training because there simply aren’t enough spots.

The answer to our healthcare woes is not to relax medical school standards and physician licensing standards.

The increasing degree burden you’re speaking of has nothing to do with physicians. Non physician provider education has been increasingly bloated by degree inflation for the sake of monetary gain on the part of the educational system. An NP, for example, used to require many years of bedside nursing followed by a masters degree. Now, you have for profit universities churning out new grad nurses who have gone straight from undergrad into all online “doctoral” NP program that allows them to practice unsupervised in some states, while having fewer than 500 clinical hours.

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36 hour surgeries don’t really happen. In the US the other staff is often given breaks and lunch’s as required by law. A different staff member replaces them for 15-30 minutes. The surgeon does not change out. So an 8 hour surgery it will be the same guy or gal the entire time.

Handoffs is one of the highest areas for mistakes to happen. Medical professionals are taught to avoid them if possible

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Yep, and as much as residents love to complain about how much they work, there really is no other way to pack all of the training a physician needs in a few years. There is still a ton to learn and master as an attending.

So typically surgeries don’t last that long anymore. Having said that, extremely complex surgeries or multi patient surgeries (organ retrieval and transplants) can be very long. Typically the surgeons will plan ahead and have a colleague who scrubs in for a portion of the surgery so they can rest, eat, take a nap etc.
The same occurs for the Anesthesiologists, although it’s more likely they would switch every 12-16 hours as even the most complex operations can be handed over without the risk of major errors.

I'm on call for 72 hours every 6th weekend, so technically, if there is an emergency case that goes for 24 hours, I'm supposed to stay. But usually for situations like that, my coworkers will voluntarily take over for a few hours so I can have a break even though they're not on call. For safety reasons of course, I speak up if I get exhausted and usually we can figure something out.

that's what malpractice insurance is for

and it's not like malpractice lawsuits are easy or successful

so why would they sleep?

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Then why not pack it in a few more years?

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No benefit to longer hours, except that shorter hours makes for a profession that is kinder to the people working in It and easier to convince people to join it. Good when we have healthcare worker shortages....

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That would be one option. But physicians already aren't making real money and starting their lives until early to mid 30s as it is. I think most residents today wouldn't want that option though. They essentially want more money for less work hours/less training. They have high confidence and really don't understand what it is like to be out on your own, making most of the decisions on your own without being able to ask your attending what to do.

I personally was happy to get done in a shorter time even if that meant several years of 80-100hr work weeks.

Not surgery related but in our icu our intensivists shifts are literally a week long. They are on site for as long as they need to be during the day (07:00-19:00 but as late as 23:00 some days) rounding /doing procedures /meeting with family /admitting new patients /consults /code team then they go home when all of that is done, but come back for any problems /crises and are on call the entire time they are not on site. We had a patient ask his long the doctors shift was and when we told her, her eyes got really large lol. It’s unfortunate but it’s the model that is the least taxing.

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There is a Socrates quote about the younger generation you should look up, just a suggestion

Does stuff like polyphasic sleep ever come up as a possibility?

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Polyphasic as a necessity more like. Jokes aside not really, the work is structured in a way that wouldn’t allow for the polyphasic sleep cycle outside of on-calls (and even then ER can wake you up at any moment). Not to mention I have yet to see research that proves that it’s a valid and sustainable alternative to regular cycle.

Just curious what happens if you get a case of the need to shits suddenly. I get why you can't leave an anethetized patient alone even for 30 seconds but still..

There is no true comparison study of these strategies and for every study looking and finding handoff errors there is another showing long shift lengths also increase errors. We very much do not know which one is “better” but physicians would argue that it’s not humane to accept a system that forces them to work 24, 36, or more hours in a row. We are already working an incredible amount of hours in a week. My point is, this is not a forgone conclusion and the biggest study looking at your argument of increased hours being superior for reduction of errors was a biased study conducted by a group of resident directors.

You sound like an out of touch attending. I hope you have little intersection with medical education.

Gotcha, thanks!

How so? What is your level of training?

Exactly, medicare funding needs to increase and be updated accordingly to allow for more residents, which would on turn increase the number of medical students, and ultimately, trained doctors.

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Absolutely. Much greater risk of contamination by having a surgeon scrub out and back in, open doors, etc.

Perhaps in the long term, but not necessarily in the short term. The process of medical school accreditation is separate from the number of residency slots, increasing program sizes, or creating new residency programs.

There are still MDs who go unmatched into programs and the job market for general practice without being board certified is very limited. I think it’s pretty illogical that in many states midlevels (usually NPs) can gain fully independent practice (FPA) shortly after graduating while physicians cannot (licenses require 1-2 yrs of residency training before you qualify for licensure).
A lot of this comes down to lobbying, unfortunately.

I work at an academic hospital with a cardiothoracic surgery training program.

Depending on the case, the attending does not always need to be present the entire time. A routine aortic valve replacement, for example, has multiple steps, some of which are more critical than others. Once anesthesia has the patient asleep, a senior CTS resident or fellow should be perfectly capable of cutting through the sternum with a bone saw and incising through the pericardium to expose the heart and great vessels. Once the attending surgeon arrives, the resident will place+connect the cannulas for cardiopulmonary bypass, and the perfusionist will deliver cardioplegia (to arrest the heart) and begin the pump run. The surgeon then joins the case hands-on for the team to perform the critical incisions on the heart and aorta. For more complex operations, sometimes the attending will call for another attending to join the case (for example one surgeon may be comfortable with the aortic valve, but may call a colleague to help if the patient needs a mitral repair or a septal myectomy). Once the aortic valve prosthesis is in place and the heart is stitched up, the team will return the blood from the cardiopulmonary bypass circuit reservoir, restart the heart, and ensure the heart has restarted in stable condition - the anesthesiologist will look with a transesophageal echo probe to see if there are any problems. If everything looks okay, the attending will leave and the resident (maybe a different resident if the first one had to leave) will wrap up, close the pericardium, close the chest, and suture up the incisions.

So the case is done in continuity, but the attending surgeon only really needs to be there for the critical part of the case. What’s “critical” vs. what’s not depends on the case, of course, and if there is significant troubleshooting because something goes wrong then that obviously requires a longer time.

TL;DR people rotate in and out of the operation to execute their particular roles when they are indicated. Not sure how it works in other specialties but I bet it’s something similar.

Do you really believe this, or have you gotten used to hearing and/or making up these excuses. If you looked at how other countries train their physicians, you would know this is not true. I mean, just by reading this, I know what country you work in, doesn't that mean something to you?

Residents are needed to keep continuity of care, and they are cheap and profitable. There's also no good reason they can't be paid more... You act as if wanting more money and less work/hours is in any way a bad thing. But clearly, because of people and a mindset like you, this is neigh unchangeable.

Just stop pretending it's a good thing that people are getting used like this.

More rest and free time add to better learning.

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I cannot imagine a continuous procedure that takes 36 hours to complete. What exactly are they cutting for such a long time?

If this is about making extremely delicate incisions in the brain of the patient or something like that, I cannot imagine that a surgeon who has been working for 35 hours and probably was already sleep-deprived when they started will do the best possible job.

Just seems very likely to me that handing over to a rested person after 12 hours or so, when some kind of milestone has been reached, would lead to better results for everyone involved.

Less work hours means less exposure to learning cases. End of story.

Also, residents certainly do a lot of work. But every decision they make needs to be supervised by an attending. A private practice attending often can do the work a team of residents does at a training facility. I really don't think they're grossly underpaid. Maybe somewhat, but it isn't like they're working in sweatshops. And, at the end of the day, they are being paid to be trained. It costs serious money to train a resident.

I'm all for more rest and free time if the number of years of training is increased to compensate the loss of experience.

A scrub is a guy who can’t get no love from me, hangin out the passenger side of his best friend’s ride tryin’ to holla at me.

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Similar to the treatment of Ignaz Semmelweis when he discovered washing hands saved lives, today's medical world ignores the facts that sleep deprivation causes mistakes which results in patient deaths.

The profession prides itself on working long hours even though evidence shows sleep deprivation is equal to or worse than being drunk. Pilots, truck drivers, air traffic controllers all work under regulated hours, but the medical world's hubris blinds them into believing they are impervious and the exception.

Medical error is estimated to be the 3rd leading cause of death in the US leading to 250,000 deaths each year. It's unconscionable that the profession does not take proactive steps to minimize these errors by starting with the elimination of sleep deprivation.

The model of working longs hours in residency was promoted by Dr. William Halstead, a cocaine addict, who expected his residents to be on-call 362 days a year and handle a workload that was difficult to maintain without artificial stimulants. It's a deadly rite of passage that continues today.

I haven't even mentioned the effects on residents and doctors themselves. Many residents and doctors commit suicide because of sleep deprivation or in the very least, develop mental illness. And guess what? Seeking mental help in the medical world is frowned upon; especially for students. Mental illness among the ranks is a mark of disgrace. The medical profession disregarding the Hippocratic Oath for their own is one of the worst ironic hypocrisies in the modern world.

That's the only reasonable alternative in your mind, which does not surprise me. Except, it is possible to train physicians without significant quality difference, with less exploitative working conditions in the same amount of time. AND there are fewer medical errors.

To me, it is truly laughable that you consider it a privilege that residents are paid to be trained when you calculate how much they bring in as revenue and quality of life for the graduated physicians. Admittedly, I don't know much about the numbers in your country, to that regard.

But why can't you do them in such a way that you got 2 surgeons working at the same time, each with 8 hour shifts but which start 4 hours apart. So you got 4 hours working at the same time, but after 4 hours one of them is changed. After another for hours one who has not yet changed is changed. Every time one who has been working longer is the primary surgeon at the moment, other assists.

That way you got 4 hours of time to get in touch with current state of the operation.

Hold it. I wish there were any other solution. Desperately hope the OB person isn't busy and can come down and break you for 5 min but they're usually busy. Your bowel habits adjust honestly.

Uh is training a resident really that expensive? At what point are they just getting money back from not having to hire mid levels.

It can be upwards of $180k per year. This was in 2014.

The Costs of Training Internal Medicine Residents in the United ... https://www.amjmed.com/article/S0002-9343(14)00596-8/pdf

It can cost upwards of $180k per year to train a resident in the US. Stop with the BS about how much revenue they bring in... they don't, and they're a liability.

When I worked at an academic center my residents were often out the door on non-call days hours before I finished. And you spend a ton of time teaching, looking for and catching errors, and explaining to angry family members why what the PGY1 said on pre-rounds was incorrect. Residents don't bring more quality of life to attending, but quite the opposite. Academic attendings are rewarded by being paid less than their private practice colleagues.

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Good thing that, in 2015, over 25% of hospitals received more than $180k in government funding for each resident they trained. https://www.fiercehealthcare.com/practices/study-suggests-medicare-overpaying-1-28b-annually-to-support-residency-programs

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All of that is true, except they’re not enough of us. Most sub-subspecialists are the only ones at a given institution. The decades of training and dedication is not something that everyone can (or wants) to do. Laws aren’t really helpful here, as obviously you’re not going to let a patient suffer just because there is no one else to handoff too. Of course, that means in the end the physician and their family suffer, but unfortunately that comes with the territory. Mostly people need to understand and have respect and patience for their doctors.

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Yes withy he exception of breaks. With breaks, even with the handovers, there is an increase in positivity of outcomes.

Great. Pay them more, and be sure to pass along some to the attendings that have final say in all decisions and bear all the liability. Don't train them less.

Paragraphs two, three and four are pretty much explanatory for each other.

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At one of the hospitals I cover, we’re down to one urologist who takes all the calls. Because the other two left and there aren’t any others to help.

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"Well, that's how I learned to do it, and I survived. These kids just need to learn to toughen up."

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Typically surgeons, proceduralists, and anesthesia are outside contractors. This varies and some or all can be hospital employees, especially when the hospital is an academic medical center.

This is how a surgeon can have what’s called “privileges” at multiple facilities.

That’s why you’re not a surgeon, right? I’m imagining this whole thread being about Navy Seals. They’re just different. It makes sense that someone who started an operation finishes it. It’s like learning an entire machine no one has ever seen, working on it, and then handing it off halfway through to someone else who has never seen it. Except the machine dies if you take to long to figure it out again.

You people seriously think that our bodies don't get used to caffeine?

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you get almost 0 effect from it at some point

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