A timeline of risks.
1960 – Jospeh Kittinger sets a world record for highest parachute jump at 102,800 feet. A part of a USAF project designed to research and test systems that would allow pilots to safely eject at high altitudes. A record that would not be touched for the next 52 years.
2012 – Felix Baumgartner sets a new world record for the highest parachute jump at 127,852 feet. 2 years of preparation with an international team of experts in everything from space travel to sport psychology set the stage for an awe inspiring, death defying feat of human achievement.
2017 – Alex Honnold completed the first ever solo ascent of El Capitan in Yosemite National Park. Alex scaled 2900 ft in a little under 4 hours. No ropes, all balls.
2018 – A team of cave rescue experts and an aeromedical retrieval physician save the lives of 13 people from the Tham Luang cave complex in Chiang Rai Thailand… under anesthesia.
For reference this is how long each person spent training for or gathering repetitions to complete their feat:
Kittinger – started working in mid 1959 to complete his jump in 1960.
Baumgartner – began his project in 2010 and trained until October 2012 when he completed his jump.
Honnold – began training in 2016 for his free solo climb.
Harris – began diving in 1979, finished medical school 1988 before he confronted an impossible situation in Thailand.
What do all of these have in common? The notion of impossible. The notion of recklessness. The notion of…risk?
The notion of impossible born of a fear of… risk? Its too risky to free solo almost 3,000ft without a safety rope (if you thought that was crazy, look into his record setting buildering in Thailand). It’s too risky to skydive from 127,000ft just to beat the record. It is insane to anesthetize a child, put him in a diving mask, tie his hands and feet, and swim him out of a cave for 3 hours.
What if you could buy down the risk?
What if every time Alex Honnold climbed something and intentionally worked to get better (rather than simply scaling everything for the pure sake of climbing something)?
What if every anesthesia case and cave rescue up to the Thai soccer team in Thailand was training Richard Harris, John Volanthen, and Rick Stanton for just that eventuality?
Each event taught them lessons they would apply to buy down the risk for the next adventure and the next…
DJ Shipley talks about this on a couple of different podcasts: The Huberman Lab and the Shawn Ryan Show (both are game changing episodes for the elite). He says quality reps, high yield training, team dynamics, and stress inoculation are the primary areas of risk mitigation. Fitness, kit selection, and mental prep are some of the minor themes that round out the concept of controlling every conceivable human element and potential fail point… so that the risk of doing a thing is mitigated to the greatest degree possible. He describes this as “buying down” the controllable margin of risk. Once chaos erupts in your face, it is too late. We have heard this said another way “getting the predictable right” from Dr. Hearns at CCTMC in 2017 and also from his book Peak Performance Under Pressure: Lessons from a Helicopter Rescue Doctor.
I believe the rescue of the soccer team from Tham Luang cave complex in Thailand is the ultimate example of this.
Thai Cave Rescue – Operation Wild Boars
12 young boys and their soccer coach became trapped 2.5km underground in a cave after a monsoon rain flooded it. The boys were located by British cave rescue divers 10 days later. Merely locating the boys and keeping them alive while an international group of rescue specialists came up with a plan to get them out would prove to be the easy part. Not only was there a cave rescue dive operation to contend with, but there was also a pretty technical rope rescue element to the operation as well to move the kids once they were out of the water.
The bulk of the rescue operation, the nuts and bolts, and the outcomes are well documented. What draws me to this particular rescue operation is the way they dove the boys out… Rick Stanton made a suggestion so crazy… that it just might work. Sedate the boys and then dive them out. The team had already encountered what would happen if they had to dive someone out who had never done it before. They nearly drowned in the process of panicking. They could expect nothing less from a little boy who had never dived before.
“Just because an activity is dangerous does not mean you have to do it in a dangerous manner.” – Rick Stanton
Dr. Richard Harris absolutely resisted the idea of rendering these boys (ages 11-16) unconscious and then trying to dive them out of the cave. It was absolutely insane and against everything he knew to be right. So incredibly insane, in fact, that no one had even come close to doing this in real life. So he had no frame of reference. Nothing on which to base his plan…
Except for how he got the idea to use ketamine. Which is somewhat comical.
A physician colleague of his was working in Antarctica, anesthetizing seals with ketamine for scientists to study. One particularly ornery seal got off of the table and ran away before he fell asleep. The troublemaker was found floating around in a pool… keeping his nose up out of the water. Protecting his own airway under ketamine anesthesia. Still stoned out of his mind.
Back in Tham Luang, Dr. Harris was looking for anyone who could talk him out of doing it if they had a better idea. The expert panel that worked this out consisted of Dr. Harris, an anesthetists from the Thai armed forces, the Chief Medical Officer of the Armed Forces, and a pediatric anesthetists from Bangkok. Between this group and the stoned seal, it was all he had to relate to and base decisions on.
How do you sedate a little boy and strap him into a dive rig… then swim him out of a cave… without killing him?
Rx:
He started with PO Xanax given to the boys about 30 minutes before he administered IM atropine (to combat hyper-salivation), and finally 5mg/kg of ketamine IM to send the boys into anesthesia. Ketamine being chosen for its known wider safety profile and being more forgiving with dosage inconsistencies.
The boys were estimated to range between 30-60kg then further subdivided into “big kid” at 50kg and “little kid” at 40kg. The rescue divers (who were not EMTs or paramedics mind you) would have to administer 2.5mg/kg “top up” doses of ketamine at various points throughout the 3 or 4 hour dive.
The Dive Rig:
The team used positive pressure dive masks for the boys. These operate similar to the full face CPAP masks we use in transport for kids sometimes. This helped keep water from filling the masks and gave the head/neck a little buoyancy that aided in keeping the airway open. They breathed 80% oxygen/20% nitrogen, and the tank was strapped to the boy’s stomach and they floated on top of it like a ship’s keel.
The Medical Pieces:
IM Ketamine provided a couple of benefits. It doesn’t take out the respiratory drive (unless slammed IV) and it doesn’t compromise the patient’s airway patency. The problems come later if the patient is handled carelessly.
The oxygen set-up was important as well. High concentration oxygen ensured high PO2. Even if they were hypoventilating then they were still breathing high concentration O2 throughout the ordeal. Which would buy time to resuscitate the boy if he were to stop breathing or go into arrest.
Positioning the boys prone with the tank under them helped to control the tongue and kept secretions away from the nose and mouth. Binding the hands and feet kept the “package” more streamlined and easier to maneuver through the narrow cave.
The Dive
With as much risk controlled for as possible, to include rehearsals for everything from IM injections to swimming through the cave, it was go time. The dive itself was incredibly technical and difficult for just the divers, and had already claimed the life of a Thai SEAL diver. It complicated things and was a source of frustration that most of the dive teams that showed up to help (including USAF PJs from 320th STS) were trained and equipped for open water diving, not cave diving. This is where Volanthen, Stanton, and Harris’ expertise in cave rescue set them apart as the lead dive rescue element.
The monsoon rains had restarted and were flooding the cave again in earnest. The oxygen in the cave had fallen to 16% (remember we are all breathing at 21%). There was no more time to practice and pontificate about the risk. If there was only 1% chance of saving one of the boys, they were going to do everything they could to give him that chance.
But none of the cave divers had ever done something this extreme and risky. Diving out an unconscious boy…12 of them and their coach to be precise.
The Win
Fortunately, it all worked and the team pulled off one of the most incredible rescues ever recorded. The first of its kind. All 12 boys and their coach survived the ordeal without any complications over 3 days of dive rescue operations. 10 divers shuttled the boys through the flooded cave complexes. After this they were handed off to a 200 person human chain using technical rope systems to move the boys through the remainder of the cave.
No one required intubation. One required respiratory support secondary to laryngospasm. NONE were reported to have aspirated. No medical person would touch the patient or assess them from the time they left Dr. Harris until they reached the human chain. No Spo2 monitors. No ETCo2 monitors. Only bubbles emanating from the masks gave an indication of the patient’s respiratory status.
Take Away
So back to this question of risk. How much is too much? I think the better question is “how much risk can you control for or buy down?” Would you accept this mission?
References
van Waart H, Harris RJ, Gant N, Vrijdag XC, Challen CJ, Lawthaweesawat C, Mitchell SJ. Deep anaesthesia: The Thailand cave rescue and its implications for management of the unconscious diver underwater. Diving Hyperb Med. 2020 Jun 30;50(2):121-129. doi: 10.28920/dhm50.2.121-129. PMID: 32557413; PMCID: PMC7481118.
https://www.bbc.com/news/world-asia-44791998
https://anaesthetists.org/Home/Heritage-centre/Collection/Richard-Harris-Tham-Luang-cave-rescue
