Thai cave rescue in the point of view of a new book

1/16/2019 - The story of the summer Thai rescue has been picked up again by the world press these days, due to a recently published book recorded by on-site reporter Liam Cochrane entitled The cave - The inside story of the daring Thai cave rescue. The same writer published a three-part series on internet containing press-excerpts from the book.

According to the editors of the newspapers presenting the book, the main strength of the book is that it writes a lot about the circumstances of the rescue, which allegedly do not reflect the conditions communicated to parents and news-hungry media of the world may have known before. News released in the summer also mentioned about some sedation during the rescue, but suggested that even in this condition, the rescued children remained somewhat vigilant, actively swimming, following the driver's guideline, participating in their own rescue. To be able for this, they learned to swim inside, in the cave, and learned how to use a respirator and a full face mask. According to the news available then, the diver was at the front with a bottle of breathing gas attached to the face mask, followed by the swimming child, and at the back another lifeguard was helping the child if they got in trouble. According to the Liam Cochrane-s book the children came to the surface as a “package” with fixed arms to keep them physically intact, to avoid jams, being moved by straps on their backs, managed by rescue divers in the water.

Because of the need for sedation, an experienced diver and anesthesiologist, Dr. Richard Harris of Australia, and his retired veterinarian colleague, Craig Challen, were asked to provide health care to the team trapped in the cave. Even before landing, the two doctors expected that there was a high risk of anesthetized transport of boys in water-filled passages, there is no clinical experience for such situations, and also there has been no precedent for such rescues. Unwilling to bear the consequences of a possible disaster, they sought diplomatic immunity from the Thai government before landing. The Thai authorities reportedly, knowing the multifaceted risks of the situation, naturally went into this and gave a quasi-free hand to a group of doctors with unique knowledge in the world.

It is important to know that there is no obligatory, approved protocol for health care in cave conditions, and on-site, depending on the given situation and condition, decisions must be made to choose from different possible therapies which are otherwise known to be useful. As time urged, after 9 days, the team was found in a weakened state and was threatened by rising water levels, declining oxygen levels in the air cavity, enriching carbon dioxide, vulnerability, exposure to tropical pathogens flooded, as well as relatively low temperatures. As a period of even more heavy rain was expected in the following days, similar to what caused the flood that blocked the team from the exit, they had to make a decision as soon as possible and the rescue team had to act. The death for unknown reason of a former naval diver Saman Gunan, further heightened both the tension and pressure on the rescue command staff.

Thai and British rescuers on the surface in a swimming pool, meanwhile, tested with the help of three young boys, one big, one medium and one smaller size, how such a rescue would work, using a full face mask. A diver guided the awake children through the pool, successfully, which gave cause for optimism. However in the narrow passages of the cave, in complete darkness, with reduced or even zero visibility, it was expected that the children would experience the situation more restlessly, which is a source of danger. In such a situation, a panic reaction can easily develop, which would most often involve false averting the danger, hoeing, releasing the face, which is life-threatening due to the possibility of suffocation. The risk of panic occurring under cave conditions and developing understandably uncontrollably under the above conditions is enormous, and its danger is invaluable. A panicked child who is not oriented in space and time and with whom there is limited communication in the conditions of a cave dive is not only dangerous to himself, but can endanger the lives of rescuers involved in the rescue very quickly.

Knowing the above circumstances and analyzing the risks, the members of the rescue team opted for anesthesia, with spontaneous breathing maintained. Although they were unsure whether this procedure could be successful, they believed that if they could save at least a few people, it could already be considered a success. Then, with the information, prospects and forecasts available at the time, this could have been a very difficult decision to make.

According to the information, the children were informed about all this, explained to them what they were up to, what awaited them during the way out. They said they accepted this calmly, were more optimistic, saying it was important to them to get to the surface at all costs. They didn't cry, they weren't scared. A “farewell letter” was formulated with them to get at least out to the anxious parents who had been worried for weeks. Eventually, one of them drafted the message and they all signed it.

A combination of three agents was used for anesthesia. One was oral alprazolam (Xanax) at a dose of 0.5 mg. This drug has sedative, mild sedative, anti-anxiety, antispasmodic properties. Effective against panic and anxiety, it puts the user in a more liberated, dissolved state. After the children were given this drug, they were given atropine into a muscle (thigh tensioner) (although the book does not cover it, a dose of 0.5 mg is commonly used), which reduces salivation and secretion production in the lungs and has bronchodilator properties. This facilitates breathing, helps maintain more stable airways, and reduces the appearance of cough stimuli. This effect was also much needed because the time spent in the conditions below and the weakness of the upper respiratory tract infections were extremely threatening to children. they received ketamine in their thighs at a dose of 5 mg / kg body weight. As it is a fast-acting general anesthetic and its effect lasts only a short time (up to about 1 hour in the first dose), they were forced to repeat 2-4 times due to the long transport time. To do this, the divers accompanying the children were given pre-filled syringes from which to inject the drug. The repeat dose was 2.5 mg per kilogram body weight. In addition to the sedative effects of ketamine, it is also an analgesic. A great feature is that it does not impair respiratory function as respiratory reflexes are retained when used. Dose-dependent dissociative anesthesia can be achieved by administration, which means a condition where the consciousness is so-called separated from perception, the patient does not remember the experience, the perception decreases. However, as a side effect, it often causes hallucinations and restlessness. Fortunately, in 15 years, when given into a muscle, these effects are rare, and because of the first time Xanax was given, children did not experience them, even if they had. The usual phenomenon after ketamine administration is that the children did not breathe for about 30 seconds, then their spontaneous breathing returned. This process was started in the presence of doctors who could intervene so that in case of unexpected reactions, the highest level of help was immediately available. After the breathing stabilized, they were dressed in a diving suit, their hands were fastened behind their backs, an oxygen bottle was fastened to their chest, and a full face mask was put on their faces. Plenty of masks were brought to the scene anyway, 4 of them were the right size for the kids, but even so, it was feared they wouldn’t close well at the little ones. Using a special harness on the diving suits, the divers were able to move the children by their backs. This was how they were able to get the sleeping children through the water-filled sections. In several places, great care had to be taken to ensure that the walls, stalactites, and a constriction around 30x70 cm did not twist or move the face mask off the children, causing a disaster. Many times, divers had to lean tightly against the wall to protect the child from getting injured. On the dry passages, the children were inspected by Craig Challen and colleagues immediately after disembarkation, their bottles and face masks removed, and how much saliva had accumulated in their mouths to see if they were breathing properly. Between the wet sections, the sleeping patients were transported on stretchers. On the first day of transportation, July 8, four children were transported to the surface, named Note, Tern, Nick and Night designated by their Coach Ek. The first-of them, the 14-year-old Note was superficial and difficult to breathe on the last ascent to the surface, but here, in the dry section of the cave, the supply was no longer such a problem. The third was the 15-year-old Nick. His breathes stopped for about 30 seconds any times when diving into cold water,  and after that restarted fine. The fourth, 17-year-old Night, who celebrated his birthday at the time of his disappearance and only joined the football team on the tour, reacted poorly to the administration of the drugs. Her breathing became irregular, so Dr. Harris was forced to leave him to lay, keeping his airways free for about half an hour, by this time his breathing had stabilized, he could start out with the help of a diver. The rescued children were transported by helicopter to the hospital, where they were segregated in a sterile room, set up their nutrition, and began their full rehabilitation. On the second day of the transportation, there was only a problem with a child who woke up underwater during transport, so he had to be given the repeated dose of ketamine there. The child does not remember this based on the narrations. On the third day, 4 team members and their coach were brought out, moreover a heavy amount of rain was predicted for that day. The coach was brought out first. The leg of 16-year-old Tee, who came out second, was caught by a rope in a siphon. The diver carrying him was forced to put him down at the bottom of the passage, go back to free his stuck legs, after which they could move on. The last 13-year-old Mark to be brought out was one of the smallest of the team members. His face was very doubtful as to whether the mask would fit, so it was the most important for him not to touch the wall anywhere. This was especially difficult because the vision already had been completely eliminated so far.

The enormous resources and the work of about 1,000 people at this stage were already helped by luck, and eventually every trapped child and everyone was able to evacuate. The people involved in the rescue did a tremendous job, with our logic, an almost inconceivable amount of rescue in an unfriendly natural environment. Despite the pressure and expectations from many places, the rescue team successfully managed and effectively conducted the rescue and also coordinated the large number of volunteers, experts, self-nominated and ambitious adventurers who arrived to the scene, and press crews from around the world. We are grateful for their work, all of us, several thousands of miles away.

The Hungarian Cave Rescue Service was available for the press as an expert both during and after the rescue. During the rescue, several of us helped the press every day to understand the ongoing rescue, to get the best understanding of what had happened. Of course, we are still available in matters concerning caves and caving, the contact details of the parties can be found on the KAPCSOLAT - SAJTÓ page. We are also happy to help to our caving friends through formal and informal channels. We have already ordered Liam Cochrane’s book on Amazon as soon as it arrives, English readers will have the opportunity to read it, but for the more impatient people it is are already available online  for about $ 15. 

Good luck!