What Extreme Athletes Teach Us About Sleep Deprivation

Transcript edited for clarity. Chris Thomas happens to be a pharmacist by day working in the pulmonary hypertension community, but he’s got a side hustle, and that is the pursuit of ultramarathon paddle racing. Picture the Yukon 1000. This is 1000 miles of cold, remote river water in a kayak paddling up to 18 hours a day. The race mandates a 6-hour daily stop, and not out of kindness. Sleep-deprived paddlers capsize, and in that water, rescue can take up to 24-72 hours. In 2023, Chris finished in 7 days on 9 total hours of sleep. Nine in 7 days. By the end, he and his brother — who happen to be two smart, high-functioning professionals — could not even add 6 hours to 10:00 PM to figure out when they had to leave the next morning for their race, they were so sleep-deprived.This is an example of an extreme experiment in acute sleep deprivation, which happens to be running on a human being. And it’s exactly why I think this conversation is worth your time in primary care because extremes make the physiology visible. I’m Dr Alison Kole, a triple-boarded pulmonary critical care and sleep medicine physician, and the creator and host of the Sleep Is My Waking Passion podcast. In this episode, what you learn is what happens in acute sleep deprivation. For example, hallucinations. Roughly 80% of ultraendurance racers actually report them, believe it or not. Chris didn’t hallucinate, but he describes half a day of continuous déjà vu. What’s likely happening is REM intrusion — basically, microsleeps that are intruding into wakefulness, which is the same mechanism we recognize in narcolepsy. So when your shift-working patient tells you they’re seeing things at 4:00 AM, it’s not psychosis. It’s sleep pressure winning. Second, you learn about the 48-hour wall. The military literature is blunt. After about 48 hours without sleep, vigilance, judgment, and reaction time fall apart, no matter how well-trained we are. Elite racers push through exactly that window. So do residents in the hospital, new parents, and long-haul truckers that are sitting right in your exam rooms. And lastly, this is where you’ll learn actionable steps that you can share with your patients or actual use yourself. What I mean by that are countermeasures with real evidence behind them. Let’s start with sleep banking, which means gradually extending sleep for 1-2 weeks before you know you’re going to have a period of sleep deprivation. Cheri Mah’s work at Stanford showed that sleep extension measurably improved athletic performance, and the military applies the same principle before they go on military operations.One caution, though, for your insomnia-prone patients: You want to extend sleep gradually. Forcing 10 hours in bed often will backfire on you if you struggle with your sleep. I can attest to that. Then there are strategic 30-minute naps that are timed to the circadian dip. You can also consider what we call a caffeine nap or a “nappuccino.” This means taking a dose of caffeine and closing your eyes for 15-30 minutes while that caffeine starts to be absorbed into your bloodstream. This means you’re waking up with both working for you, the nap and the caffeine. And please, don’t miss nutrition. Chris’s worst crash on the river wasn’t sleep deprivation at all. Turns out it was underfueling and electrolyte imbalances that were masquerading as exhaustion. Now, your patients aren’t paddling the Yukon. I get that. But they are working nights, they’re taking call, they’re raising newborns, and they’re chronically running on less than 6 hours, and they’re all calling it normal. Chronic short sleep tracks with multiple issues, including hypertension, coronary artery disease, diabetes, impaired immunity, and impaired clearance of metabolic waste from the brain. Here’s the reassuring thing: Cohort data on Olympic athletes suggests that intense training with intermittent deprivation in people who otherwise recover well didn’t necessarily cost them longevity.They lived about 5 years longer than the general population. Dose, chronicity, and recovery do matter. Chris’s coach calls sleep a performance-enhancing drug. I’d go a bit further. I’ve said it before and I’ll say it again: Sleep is a vital sign. You want to ask about it in the way you ask about blood pressure, especially in your higher achievers who are usually the last to admit that they’re actually running on fumes.If this made you curious, the full conversation is in season 6 of the Sleep Is My Waking Passion podcast. You can get it wherever you get your favorite podcasts. Though I prefer for you to check it out on YouTube so you can see the video too. It’s a fun one. Kayaks, hallucinations, and a practical playbook for the sleep-deprived humans in your practice. And if we’re really being honest, one of whom may be you.