An interview with Dr Richard Harris
Dr Harris receiving the Pask Award from Dr Kathleen Ferguson, President of the Association
Adelaide born and bred
DH: I’m David Hatch. I’m here at the Association of Anaesthetists on the 14th December 2018 with Dr Richard Harris, the Australian anaesthetist who’s just received the Pask Award for his part in the rescue of the young boys from the flooded cave in Thailand.
Richard, thank you very much for coming. It’s a pleasure to have you with us.
RH: Thanks David. Thank you for having me here.
DH: Let’s just start at the beginning. Where were you born?
RH: So I’m Adelaide, South Australia born and bred and I’m still working there now, but I’ve moved around a few times over the years. So yeah, started life up in Adelaide.
DH: Your father was a surgeon I think, wasn’t he?
RH: Yeah, he was a vascular surgeon who, like many people in that era, came over to the UK and did a lot of his training here in Leamington Spa and Warwick Hospitals.
DH: And your mother, was she medical as well?
RH: She was a nurse who was English, she was from Lancashire originally but she was training with her nursing in Leamington Spa, and that’s where her and dad met and he brought her back to Australia, I think at the tender age of about 24. So she became Australian after that.
The student years
DH: And you went to school in Adelaide, did you?
RH: Yeah, went to school in Adelaide and then university at Flinders University.
DH: What influenced you to make that decision, to study medicine?
RH: Well I’m sure it was partly growing up as the son of a doctor and my two uncles, dad’s brothers, were also country GPs in rural south Australia and Victoria, and in fact their father and his brother were both doctors in the Riverland, in Renmark, third generation for me, and I’m the last of the line! The only one and it doesn’t look like there’s going to be anymore.
So I got married in 1990 to a girl, Fiona, that I’d met at medical school, and so we both decided we’d come over to the UK in 1991, and we worked at Warwick Hospital, again partly because dad had been in that area and some of mum’s relatives were still around that area. So spent a year in Warwick doing my first year of anaesthesia and ICU as an SHO at Warwick Hospital.
DH: Had you decided you wanted to be an anaesthetist before you came to UK?
RH: No. In fact I was very certain that I was gonna be a country GP and in Australia you can still work in remote areas and do some anaesthesia and some obstetrics and surgery, so that was what I was pretty keen to do, but after about 6 or 8 months in the UK I really felt strongly that I wanted to be an anaesthetist and applied to the training programme back in Australia and was lucky to get a spot there.
DH: Was there anybody in Warwick that particularly influenced you, that you remember?
RH: I was very impressed with a number of consultants there. David Tweedy was the chap who was the consultant, the boss there, and I haven’t really kept in touch with any of them to be honest but I remember the registrar, the proper training anaesthetist, was over at Leamington Spa doing obstetric anaesthesia which left the SHOs [Senior House Officers], a group or five of us, at the hospital after hours doing all the ICU and general theatres, so that was pretty busy and I really got thrown in at the deep end. It was fairly harrowing actually for the first few weeks and months.
DH: I seem to recall you telling me you did your first appendix after a couple of weeks?
RH: Yeah, you’d be on Saturday, Sunday, Monday, sleeping in a little pigeonhole in the ICU and running the ICU for the weekend with the consultant coming in for a round in the morning, and then doing all the cases in theatre as well. And I can remember one night being in theatre doing a case and the intercom on the wall of the theatre going off repeatedly and it would be one of the ICU nurses telling about a patient with hypotension or something so you’d be managing a patient in ICU over the intercom with the other eye on a patient in the theatre and it was pretty testing, but I think the training here at that time seemed to really revolve around bringing you up to a level of independence and self-sufficiency very rapidly with that Diploma of Anaesthesia, the part 1 that I did at that stage, and when you’re in theatre with the consultants doing elective lists, it was just constantly failed intubation drill, what are you gonna do? Anaphylaxis, what are you gonna do? Patient’s bleeding, what are you gonna do? It was just constantly testing you on those practical survival skills. So for a new anaesthetist, a new trainee, it was actually a really good way to learn. You didn’t have to worry about the physiology and the pharmacology too much, at that stage. It was really about surviving and keeping your patients alive, and as a starter for a practical approach to anaesthesia, it was brilliant.
"It was really about surviving and keeping your patients alive, and as a starter for a practical approach to anaesthesia, it was brilliant."
DH: It was very much an apprenticeship more than a taught course.
RH: It was. I can remember the old ODAs [Operation Department Assistants] in the theatres sometimes I would be saying to the ODA, ‘I’m thinking about doing a spinal on this case’ and this old boy would say, ‘Oh … don’t know about that one Dr Harris. What about popping a tube in?’ And they’d save your bacon a lot of times. Very experienced old guys.
DH: You probably could have done with an ODA in Thailand.
RH: I think so, yes!
The diving bug
DH: What gave you the diving bug in the first place?
RH: Growing up in South Australia, dad was a very keen boatie, small boats and fishing was his big passion. There’s a table fish in South Australia called the King George Spotted Whiting, which my dad was completely and singularly obsessed with, and so all his spare time was out in a little boat trying to catch these fish, and they were delicious I have to say, but we’d be out, not far off shore, shallow water, they’re only small fish, they’re not exactly a game fish or anything, and I’d always be looking at the horizon, looking at these offshore islands and saying, ‘Dad, why don’t we get a bigger boat and go out there? We could catch a shark or something huge out there! Why do we have to catch these piddling little things?’ And he wouldn’t be swayed at all so around the same time, as an early teenager I guess, I was doing a lot of snorkelling and spear fishing, and then it was actually a family friend who owned a dive shop in Adelaide, a very famous South Australian personality called David Birchall, who lost one of his legs in at train accident, as a teenager, and despite that he went on to be an incredible athlete, he was a gymnast and could do all these amazing tricks and flips and things, huge, robust man, hugely powerful upper body, and he was a scuba diver, and one of the very first scuba divers in Australia really, who started to do it recreationally. And then he got involved with the police divers and was training them, and he set up this dive shop in Adelaide called Adelaide Skin Diving Centre. So because I knew him I used to ride my bike in there after school and go and visit him, and they had this great big training tank which was about 25 feet deep in the back of the shop, and so finally I did my diving course when I was about 15 years old there, and then I’d pop in after school and go and test gear in the tank and hang out with the people in there. So I just became really immersed in it, literally, very early on, and it’s always been a big part of my life.
DH: And did you start diving for real in the lakes and roundabout?
RH: So from the caves point of view, I started doing that in 1985 when I was still at university. I was part of the Flinders University Dive Club and a few of us became diving instructors there and started running courses within the club, so it was quite an exciting time. Very big, busy club, sports club at the uni.
Bonding over disaster
DH: So you got quite interested in caving fairly early on in the diving, as opposed to diving in the sea water.
RH: Yeah, we’ll I’d done all this ocean diving for a long time.
DH: And were there any particular cavers that influenced you?
RH: There were actually, because the chap who taught me my basic scuba diving open water ticket at Adelaide Skin Diving Centre was a guy called Ron Allum, and Ron has gone on to become quite a big figure in the diving industry worldwide, because he was the guy who built the submersible submarine for James Cameron to do the Mariana Trench expedition a few years ago, the Deep Sea Challenger, which they made a movie about. So Ron was my diving instructor when I learnt to dive and in fact I had a bit of an incident the first year after my diving course, in fact I was still 15 years old, and Ron took a group of us out on a very small boat on a very rough day, out to a wreck off Adelaide, and we dived the wreck and when we came up it was even wilder, the weather, and on the way back in we flipped the boat over and spent the night in the drink from about 5 pm till 7:30 the next morning. It’s quite a notorious area for great white sharks, that gulf we’re in, and it was a pretty gruesome night I have to say, but me an Ron kind of bonded I guess over that disaster!
DH: I should think you either bond or hate for the rest of your life after an experience like that!
RH: Yeah.
"It’s quite a notorious area for great white sharks, that gulf we’re in, and it was a pretty gruesome night I have to say, but me an Ron kind of bonded I guess over that disaster!"
Getting involved in MedSTAR
DH: And at some stage you got involved in MedSTAR, the South Australian Ambulance Service group. When was that?
RH: I went back to them in 2012 after … retrieval has evolved quite a lot in South Australia over many years, but it basically used to be based in the intensive care units, and I worked there as a registrar but then didn’t do much until I decided to go back to it in 2012, and by then MedSTAR had just been formed, a couple of years before that, and had been incorporated under the ambulance service, and we’ve got our own base and central point of coordination, so you don’t have to ring around the ICUs looking for a retrieval or a bed anymore; you just ring one phone number wherever you are in South Australia, you’ll get one of our retrieval consultants, like myself, on the phone, who’ll give clinical advice and then organise the logistics of the retrieval and find an ICU bed for you, so it’s kind of a one-stop shop, which we’re quite proud of, now.
DH: And you’re now the head of coordinating –
RH: Yes, so coordination is a big part of the retrieval service, going through those steps I’ve just mentioned, and I’m currently the head of the unit for retrieval coordination, which basically means I’m in charge of the consultant group and all the logistical stuff, but I guess it’s like an operational lead.
DH: And this is for retrievals of all sorts, is it? Or mainly helicopter, or fixed wing?
RH: It depends how far away. In South Australia obviously there’s some pretty massive distances to cover, so if it’s within the Metropolitan area we’ve got little physician response cars, same as London does, so we’ll drive out in those. Or if it’s within a couple of hundred kilometres we’ll take the helicopter. If it’s further afield then we use the RFDS fixed wing aircraft. We subcontract them to provide that aircraft for us to go out further afield. So that’s for any critical care requirement in the state comes through to us.
"The most frightening caving I've done"
DH: And going back to the caving then, you’ve done some quite impressive cave dives I think. One I was reading about, in 2011 you tried to find the source of the Pearse River, is that right?
RH: Ah, the Pearse Resurgence, that’s kind of been the signature project for our little group of divers, we’re just a bunch of mates really. I first went there in 2007 with some guys who had been exploring it for a few years, and they had explored it down to a depth of 125 metres, and actually on that trip is when I first met Rick Stanton, who’s the British cave diver who was in Thailand, who called me out, and Rick is an astonishing guy! He’s, I don’t think anyone would disagree in the caving community worldwide that he is the leader and he’s just on the cusp, in fact he keeps trying to retire but he keeps getting called out for all these sort of jobs, but Rick is an extraordinarily pragmatic, intelligent, sensible guy who has just done these exceptional things worldwide in cave exploration. So Rick came and, from 125 metres Rick, using this funny old homemade rebreather that he’d built out of bits of PVC and so forth, he dived down to 177 metres in this cave, which nearly doubled the length of the thing. It was just completely eye-opening for me and that was in 2007.
So on the back of that I went back to that same site with a couple of guys the next year and I dived it down to 182 metres, and then after that then going back almost every year with a slightly bigger team and myself and Craig Challen, the chap I took over to Thailand with me –
DH: The vet?
RH: Yeah, the vet. Retired vet now, he happily says, we’ve now pushed that cave down to 230 metres in depth and quite a significant horizontal distance as well, so it’s become a very complex logistical exercise, that cave.
DH: Is that the most difficult caving you’ve done?
RH: It’s certainly the most frightening caving I’ve done! Because at that depth… I find the physiology of deep diving really fascinating because there’s all sorts of issues that arise in terms of gas density and gas toxicities and things, that don’t really become apparent until you’re at about 150 metres so beyond that depth you’re starting to really … push the envelope in terms of safety and what you can do, but I do strongly believe it can be done safely with certain things, carefully organised and staying within some parameters. So for me it’s been a real exercise in logistics and safety and working out a way to do this very slowly, which is why we’ve taken so long to get so far I guess.
"Push the envelope in terms of safety and what you can do, but I do strongly believe it can be done safely...within some parameters".
DH: Just tell me where the Pearse River is. I’m afraid I don’t know.
RH: It’s in the South Island, on the north end, just west of Nelson, which is a beautiful town with lots of boutique breweries and excellent beers! Which is also an important thing to think about when you’re planning a diving expedition! So it’s a long way out into the bush. In fact we have to fly in a helicopter to get to the diver site, and take all our gear in by helicopter, so it’s a fairly major expedition.
The Wild Boars
DH: Well let’s move over to the Thailand episode, which I’m sure a lot of people will be interested in. Rick Stanton, he’s an Englishman, he’s up in the north somewhere, isn’t it?
RH: Yeah, he lives in Coventry, and he’s a firefighter, also just retired, starting to worry about all these blokes; they don’t’ seem to wanna work anymore!
DH: And he was the person who asked you to join him, did he?
RH: Yes. So he and his dive buddy, a guy called John Volanthen, who lives in Bristol, they and a guy called Rob Harper, who’s an older guy, a very good caver still but hasn’t done much diving for a while, they got called over by a British ex-pat who lives in Thailand who’s a caver, who recognised that the rescue wasn’t proceeding and in fact the search wasn’t even proceeding at that stage, and that they clearly needed some cave divers to come over and help push further into the cave to try and find the kids, so this guy Vern Unsworth, who was the local caver, sent out – wrote down these three names on a piece of paper, gave it to one of his contacts in the government who then passed it up the chain until someone said, ‘OK, we’ll authorise these three guys to come over from England.’ So they got flown over fairly early on in the piece, and at that stage the cave was still flooding, the water level was going up and it was an extremely hazardous environment at that stage. In fact when they arrived they couldn’t even get into the cave because of the volume of water coming out of it.
DH: Let’s just recap what had happened before this. These lads, how many were there?
RH: So twelve boys and their coach from the Wild Boars soccer team in Chiang Rai province, which is the most northern province in Thailand. Basically on a Saturday afternoon after soccer training, I think it was one of the kids’ birthdays so they said, ‘Let’s go for a bit of an adventure into the cave. We’ll just go in for an hour and then come back out in time for the birthday party for one of the boys, and some of them had been in the cave before. This was their back yard, is the local place to go and have an adventure. And there’s a sign up outside the cave saying, ‘Danger – do not enter the cave from July to November’ I think it is, because of the monsoon season and the risk of flooding of the cave. This was June 23rd so they were just inside that window and it’s a bit unfair really that the rains had already started up in the mountains when they entered and that there was a bit of monsoonal downpour after they entered, and so the cave flooded while they were inside and they were trapped about 2.5 kilometres into the cave.
DH: So they’d probably gone further than they originally intended anyway, hadn’t they?
RH: Yeah, so we know now that when they turned around to come back they were walking back out and then suddenly realised they were walking in water when it wasn’t wet before, and then suddenly they got to this point where the water met the ceiling and they realised they were trapped. And the coach, to his credit, tried to dive through that attached to a piece of rope, and couldn’t – ran out of breath and had to turn around and the kids pulled him back in. So at that stage I think the water was still rising, so they had to retreat into the cave to find higher ground, and finally found this muddy embankment, very steep slope, where they huddled up the top of that, about 15 metres above the water. So they were at a pretty good safety margin at that point.
"Suddenly they got to this point where the water met the ceiling and they realised they were trapped."
DH: But they were about four kilometres in, were they?
RH: About 2.5. That’s been a bit misreported in the media, that distance, but yeah, 2.5 kilometres probably from the entrance.
DH: So what was the scene like when you arrived?
RH: Well we got called, I’d been in communication with Rick Stanton and another diver from Belgium who were on site, and just talking through the problems and the options, and as you can imagine it’s fairly chaotic ‘cause really no one knew exactly what to do.
DH: Yeah, the language problem as well I suppose.
A sense of doom and dread
RH: There was the language problem and this was a completely unprecedented event worldwide. No one had ever thought about how to deal with something like this. There’d been the miners trapped in South America a couple of years before that, when they drilled a little borehole down to the mine and then put in the bigger hole and then brought them out with that cage, but the problem here was that the map of the cave wasn’t accurate enough to know how to drill down from the surface to the exact spot where they thought the kids were, and the water was still flooding out of the cave. No one could get in there to safely even look for the kids really. So when the British cave divers arrived there was a great sense of doom and dread I think that the kids were almost certainly dead inside the cave, but they had to start searching. And then eventually they did push their way into the cave and lay a rope through the cave, which was an enormously difficult task to lay a thick rope throughout the cave into the face of flooding waters.
"This was a completely unprecedented event worldwide. No one had ever thought about how to deal with something like this."
DH: And the Thai divers did that, did they?
RH: No, the British divers did that, Rick and John. And that, in my opinion, was the single greatest diving achievement of that rescue. Very physically difficult and dangerous job to push into an unexplored cave essentially and laying a rope as you go for other people to follow.
DH: And John was still doing that when he came across them?
RH: Yeah, so they both surfaced in that chamber, where the kids were, and their technique was to surface in each air bell and take their mask off and call out and also sniff the air to see if they could smell any … hint of human presence. And on this last time they surfaced in the chamber they were actually at the end of their line so they had run out of rope for that day so they would have had to stop there anyway and come back the next day with more rope. And they put their heads out and smelt the air and immediately knew there was either living people and a lot of excrement and waste in there, or dead bodies, and they were still expecting really to find bodies at this stage, so pretty tough psychologically for those guys.
Anyway, they called out and suddenly heard a commotion and an answer, and so they swam round the corner and there’s all these kids sitting on the mud. Unbelievable. So what an amazing moment that would have been!
"We’re not expecting to find them alive..."
DH: And you were there at that stage, were you?
RH: No, I was still in Australia, and as I say I’d been communicating with the guys and Rick had said, ‘There’s probably no point coming over yet, we haven’t found the kids. To be honest we’re not expecting to find them alive, so probably don’t need any more help.’ But once they did find the kids then of course the next thing is how to get them out, because the chances are the monsoons are about to really start properly, in which case it’ll return to that fully flooded situation where they won’t be able to even get into the cave to supply the kids with food or contact them again.
DH: And presumably the ledge the kids were on would have been flooded then, would it?
RH: Well we’ll never really know the answer to that. It was pretty high, but you wouldn’t wanna put it to the test. At the very least they would have ended up sitting on a very small area of mud in a very stale atmosphere, a small pool of water for gas exchange – they probably would have run out of oxygen and CO2 [ carbon dioxide] would have gone up.
As it was, there was quite a big cavern there with some movement in the water so the air in the cave where they were wasn’t too terrible, although as I say the smell was pretty fierce. So yeah, Rick, I was in the operating theatre actually doing a thyroid, I remember, and had been exchanging messages with Rick on the phone, and he actually rang me up and said, ‘Look, we’re a bit stuck here. We’ve actually got no way of getting these kids out. The monsoon’s going to start again any minute.
"We’ve actually got no way of getting these kids out. The monsoon’s going to start again any minute."
There’s been a lot of attempts to lower the water levels with pumping, and it might be controlling the water level but it’s certainly not lowering it. They’re trying to find an entrance from the top of the mountains but the feeling from the geologists is that there won’t be a connection. They’re trying to drill down from the surface but they’ve got no way of knowing where they are in relation to the cave so it’ll be a one in a million if they manage to find a way down with a drill, so we need to get these kids out. And the only thing I can think of is to sedate them. Would you be prepared to come over and do that?’
And my immediate response was, ‘Absolutely not! I can’t think of a more certain way to sentence those kids to death than give them an anaesthetic and then try and bring them out under water 2.5 kilometres.’ But I did say I’d be happy to come over and help, and maybe I can swim in and give the kids some medical support while we’re waiting to work out what the plan is, or whatever.
"My immediate response was, ‘Absolutely not! I can’t think of a more certain way to sentence those kids to death than give them an anaesthetic and then try and bring them out under water 2.5 kilometres.’"
DH: So when did you first dive there?
RH: So we arrived on a Friday morning, I was told to go to my hotel, that I couldn’t even go and look at the cave until I had got my authority to practice as a doctor in Thailand. I don’t know what they thought it was going to do by just going to have a look at the cave but anyway I was confined to barracks in the hotel and about 5 pm that day I got word from the Australian diplomatic people that OK, we’re good to go up to the cave. So went straight up and Craig, from Western Australia, had arrived at that stage, we went up to the cave to meet with the British cave divers, and had a meeting with them and just confirmed all the stuff that I’ve kind of talked to you about, that things were pretty dire and there was no immediate plan to rescue the kids, no one knew how to go about it.
So we talked through this idea of sedation and I talked to some of the Thai medical specialists on site about that, and they wanted to know what I was thinking and I don’t know if you’ve ever tried to convince someone else of a plan that you have no faith in yourself but that’s what I felt like I was doing!
"I don’t know if you’ve ever tried to convince someone else of a plan that you have no faith in yourself but that’s what I felt like I was doing!"
Anyway, I said, ‘Look, I can’t even think about rescuing the kids until I’ve managed to swim in there myself and have a look at the kids and make sure I’m safe in the cave and that I can physically get to the end of the cave and back without endangering my own life, and so the next day Craig and I left at about 10 am to enter the cave, managed to get to the end of the cave in about three or four hours, it was fairly hard going but not the worst we’d done, so at least I was confident that I could do the dive.
DH: Was there much of a current?
RH: Yeah, there was still quite a strong flow so you had to pull yourself hand-over-hand along the rope for 2.5 kilometres, so it was pretty big day out.
DH: Was it harder getting in or getting out?
RH: Much harder going in, easy going out although you have to be careful not to lose the rope on the way out, because as you come out all the silt and mud is following you out so it’s really zero visibility, so it’s just hand on the rope and let yourself get floated along by the current.
DH: But it wasn’t the most difficult cave diving you’ve done?
RH: It wasn’t the most difficult, I mean it was pretty sporting, there were a couple of these sumps, which are the underwater sections where they’re very restrictive passages so you had to feel your way around to find the bit of cave that you could fit through, essentially like trying to find your way out of this building with your eyes closed if suddenly all the lights went out. You know, you’ve got some familiarity with the cave and you’ve got a bit of string to follow, but you have to feel your way along.
Making first contact
DH: How did they find it the first time when they were, before they had the string?
RH: That’s what I mean, it’s just an extraordinary bit of diving by Rick and John to find those kids. Although to be fair there was only one tunnel and you just point your nose into the current and you know that’s where the tunnel goes. But nonetheless, there’s some very restricted parts of the caves, so they did very well.
DH: So you got there in three hours, and did you take any equipment with you?
RH: We took some food. Initially we thought we’ll take some food for ourselves but of course once we got there and started talking to the kids, well immediately we gave them the food and they wolfed that down!
DH: And did you do any sort of medical assessment of the kids?
RH: So there were four Thai divers in there with the kids, they’d gone in there quite early on and they’d been pretty much stuck there since because they’d used up all their air, so they couldn’t escape themselves at that stage.
DH: One of them was a doctor, wasn’t he?
RH: One of them was a doctor, yeah, an amazing guy, lieutenant colonel in the army who was also trained as a special forces diver, and was also a GP I think with the armed forces, so an extraordinarily multitalented guy and very charismatic, very happy, smiley bloke, amazing morale booster for the kids having a guy like that in there and three other Thai Navy SEAL divers. So pretty tough bunch of guys and incredibly brave because as I’ve mentioned, without cave diving training that’s a really dangerous dive to attempt for them, and the risk is shown by the fact that they’d used up all their gas without leaving themselves enough to get out again.
A casualty
DH: And of course one of them had died by this stage hadn’t he?
RH: And also shown by the fact that one of their colleagues had died the day we arrived actually, had presumably run out of air in a very restricted part of the cave and couldn’t find his way out in time. So through Dr Pak who spoke quite reasonable English, I just did a bit of a systematic review of the kids. I could hear a couple of them coughing in the background so I think some of them had early chest infections, but apart from that, apart from a few little cuts and scrapes on their legs and things they were all in really good shape. All standing up, walking around. They’d had a bit of food brought into them by then so they were bouncing back a bit from the weakness of nine days’ starvation.
DH: And not much sleep I suppose.
RH: No, they would sleep for an hour and then wake up, sleep for an hour then wake up. They were chilled to the bone the whole time and losing weight because of that and the lack of food.
DH: Did they have nothing to sleep on except the rock I suppose?
RH: Just mud and rock. So they’re damp the whole time. Pretty awful. It was a pretty grim spot.
DH: Remind me what their age range was.
RH: So the youngest was 11 and the oldest was 16 and the coach was 25, and ranged from 29 kilos up to about 65.
DH: But you didn’t know their weights?
RH: I was given a list of their weights before the first rescue day, by one of the local doctors, and they must have got that from the parents perhaps. But then I actually asked each kid as they, through Dr Pak, the interpreter, I asked each kid for their weight as they came down for their little anaesthetic and the weights seemed to correlate pretty well, with the exception of one that we were caught out with, the last kid, who we thought we’d done all the small kids and then the last kid turned out to be the lightest, the 29 kilo boy, so that it was a bit of a problem actually ‘cause the facemask that we had for him wasn’t the right one. So there’s another story in that.
DH: So having done that assessment you then went back the first day, did you?
RH: Yeah, so we spent a bit of time, we did some video of them for their parents, ‘cause every day we left there was a distinct possibility the rain would start and we wouldn’t get back in, so there was a chance every day we saw them that we’d be swimming out and never see them again and they would be left to die. So I got some video of them and we got them all to write a note for their parents, to take out as well, but told them through Dr Pak that we would be coming back the next day and that this would be the plan, and they were gonna ask them to fast six of the kids from 6 am thinking we’ll be in at about mid-day for them.
"There was a chance every day we saw them that we’d be swimming out and never see them again and they would be left to die."
DH: So you had made the decision that you were going to sedate them?
RH: Yes.
The only chance
DH: When did you change your mind from saying ‘no way’ to ‘this is the only chance’?
RH: Well really it was during that day, I think it was probably that morning that Craig and I did our first dive, that after a night of meetings and discussions with the British divers and all the Thai rescue authorities, it really seemed like there was no other option for bringing the kids out unless they were sedated. We talked about every conceivable plan, teaching them to dive, restraining them somehow so that if they panicked they wouldn’t thrash around and endanger the lives of the divers, but really it would be too cruel to inflict that on the kids without having at least some sedation on board. But yeah, I just …
DH: So you came out and got your ketamine ready, did you?
RH: Yeah, so of course the next question was what drugs were we going to use, and I spoke to a friend of mine in Australia –
DH: This is the guy who’d given ketamine to a seal?
RH: Yeah, so this guy’s a very practical fellow who I have enormous respect for, he works at the retrieval service, and he’s a country GP who does a bit of anaesthetics, obstetrics, a bit of surgery, and he spent four years in Macquarie Island in Antarctica as both a scientist and a doctor, and yes, as I say, he anaesthetised seals for the scientists before and had one experience where the seal escaped before it fell asleep and was later seen swimming around with its nose out of the water without any worries at all, so protecting its own airway under ketamine anaesthesia, so that was the closest experience we could relate to this story so we decided that sounded like the best drug. But of course there’s really no alternative in terms of if you want to maintain an airway, respiration and some sort of blood pressure there really isn’t any other choice.
DH: And how did you decide on the dose then?
RH: Well, whilst I had given a large amount of ketamine over the years, particularly when I spent two years working in Vanuatu, which is something I didn’t mention but I spent two years over there, so I was very comfortable giving ketamine anaesthetics, but what I hadn’t really done much of, if any, was intramuscular ketamine, so with the idea that keeping things as simple as possible would be sensible, I decided it would be intramuscular ketamine given through the wetsuit into the thigh, and based it on 5 milligrams per kilo as a good starting dose and then a half-dose thereafter of 2.5 milligrams per kilo if the kids needing topping up on the way out.
DH: Which they did.
RH: Which they did, yeah. At least twice and often up to four times on the way out.
DH: So you had to presumably train the people in the pods coming out? How did they give the ketamine?
RH: The other divers, a mixture of British, European and one Canadian cave diver, we had about twelve or fourteen of us in the end who were able to go into the cave and help with the rescue, so I remember giving this anaesthetic lecture to them on the morning of the first recue day and I had to again convince these guys of a plan that I had very little faith in, and try and assure them that it was an inherently safe technique and there was nothing for them to worry about. They all practiced giving an intramuscular injection into a water bottle, that was their one practice run, and then Craig, my dive buddy who is the vet, obviously he has significant experience with ketamine and with injections and things, I put him at the first dry chamber after the first diving section, so that he could do the initial assessment as each kid came through, and he could also use that as an opportunity to teach some of the divers, or supervise their first injection ‘cause they’d be pretty much on their own thereafter. And that system seemed to work pretty well.
DH: And they knew the weights of each child coming through did they, or the dose that they were to give?
RH: No, so to keep, again to make it as simple as possible and to try and avoid errors what I did was divide the kids into, and remembering that they were basically between 30 and 60 I decided to call them all either 40 or 50 kilo kids and then so the divers were given bags of drugs labelled ‘big kid’, ‘small kid’ top up. So I had 2.5 milligram per kilo based on 40 and 50 kilos, so the smallest kids were getting a bit much and the biggest kids were getting a bit too little and a few of them were getting just right sort of dose. And that seemed to me the safest way to do it in the hands of lay people. I had to just eliminate all the decision points that I could, so they would have the confidence just to do something rather than do nothing I guess.
The second day
DH: So that’s the first day and night. Then you went back the second day.
RH: Yeah, so after this first day that Craig and I just went to visit the kids and make sure we could do the dive, we came out at about 9 pm and then we were in meetings until about two in the morning I think with firstly back to all the medical specialists, there was an anaesthetist there and the Chief Medical Officer for the armed forces was there and a couple of other navy doctors and they were thrusting a telephone towards me saying, ‘Right, now you’ve got to speak to this paediatric anaesthetist in Bangkok and tell them the plan,’ and they’d be saying, ‘Why have you chosen this and what dose are you going to use?’ and I was just once again going, ‘Look, if you guys have got a better idea, I’m open to it.’
I had no idea whether it was gonna work or not. Anyway, they all seemed happy for me to I think take responsibility for this plan at the end of the day, and yeah … so they ended up giving it the rubber stamp and then I had to go up the hill to the bigger planning meeting where the Minister for the Interior was in the room and he was the guy who seemed to have the authority to give the whole plan the green light.
And the King or his representative was on the phone and the Prime Minister was on the phone into the meeting and so we all had to present our part of the plan. And then they came to a decision that yep, it was all go for the next day. So I got to bed about half-past-two in the morning I think, after being in a cave for 12 hours, got about 2 hours sleep and then back into it the next day.
"The King or his representative was on the phone and the Prime Minister was on the phone into the meeting and so we all had to present our part of the plan."
DH: With the ketamine.
RH: With the ketamine.
DH: And some anxiolytic, [medication to reduce anxiety] is that right?
RH: So yes, I gave each kid a tablet of alprazolam, tried to get that into them about half an hour before their turn, and the idea behind that was a) just to give them a bit of anxiolysis before they came down the slope, of course I’d forgotten about the fact that they’d be a bit drugged while they were walking down this steep, muddy slope; they were all a bit wobbly but they all seemed to be alright.
DH: And they were starved, were they?
RH: Yeah, I got them to be fasted from 6 am for a roughly midday start. And I gave them a dose of IM atropine into one leg and then IM [intra muscular injection] ketamine into the other leg, just to try and decrease the secretions in the mask.
Keeping the boys alive
DH: And tell me about the equipment then and the steps you tried to take to … well obviously successfully … for them to maintain their airways.
RH: Well the two biggest concerns I had were that as a diver you’re constantly and unconsciously, once you’re experienced you’re constantly removing water from the mask, even with these full-facemasks that we sometimes use for filming and other reasons when you might need communications for example. So I just thought that inevitably at some point the mask will get water in it and the child will drown inside the mask.
Also knowing that the number of times we were banging our own head in this low visibility water on the pendants and stalactites coming down from the ceiling, you often smack your head into them as you’re leaving or swimming through the cave. I thought at some point the mask will get bumped and dislodged and will fill up with water so that was my first concern. I thought even if they don’t drown, surely their head will fall forward and they’ll obstruct their airway at some point and these divers, not being anaesthetists, won’t … despite me trying to tell them to make sure they just try and hold the chin up where possible, at some point they’ll obstruct their airway, and if that didn’t kill them then I thought well they’ll probably die of hypothermia ‘cause the water’s only about 20 and if they –
DH: And they were cold when they started.
RH: Already cold, they’re skinny, they’re in badly fitting wetsuits and they’re going to be immersed under anaesthesia for three hours. I mean …
"They’re skinny, they’re in badly fitting wetsuits and they’re going to be immersed under anaesthesia for three hours..."
DH: And the masks weren’t ideal, were they?
RH: So the masks, we sorted through lots of different brands and there were literally hundreds of these facemasks sent from all over the world for us to look at and try, and we ended up with one specific one which seemed to fit the kids we tested it on some local kids and also had positive pressure in it, so a bit like fireman use for smoke-filled scenes or where there’s toxins, poisons in the air, and positive pressure to make sure nothing comes in, including water.
100% oxygen
DH: And was that oxygen or air or –
RH: So we wanted to use 100% oxygen and the theory for that was that like with any anaesthetic if they’re hypo-ventilating that that will help maintain their oxygenation. Also given that the kids are probably all getting chest infections, that would be a good thing, but also if a kid did drown and had 100% oxygen on board then it might prolong the time to successful resuscitation if that was possible. So I thought it might just give us a little extra safety margin there if one of them did drown and you could race them through to the next dry chamber and improve the chance of resuscitation.
DH: And did you take the temperature of each child before it was –
RH: No. Picture yourself floating in a fairly disgusting pond of stagnant water full of all sorts of unmentionables and kids sitting on this dreadful, sloppy mud hill, really there was no time for anything in terms of monitoring or assessment.
DH: But you knew they were cold.
RH: Yeah. They all said they were cold. They all were shivering.
DH: And you found out afterwards that the lowest temperature was 29 I think.
RH: Yeah, so I’ve got all the observations from the Thai doctors on all the kids afterwards and yeah, the lowest temperature was actually the coach, one of the bigger ones, was 29.3 I think at first measurement, so getting down there.
DH: So you decided not to send too many kids through at once to start with?
RH: Well we toyed with a variety of plans. The British initially wanted to bring six out all in a chain, pretty much all at once, and my view was that because the different parts of the cave were very restrictive, if there was any kind of problem anywhere in the chain then you’d get a bottleneck and people piling up behind them and it would be like a traffic jam underwater in zero visibility and that’s always going to end in disaster. So I said let’s just try and do four kids on each day and let’s have a good separation between each one, just one diver per child taking responsibility all the way through and we’ll station some other divers along the cave to assist them in the dry sections or the drier sections.
The other divers can help top up the anaesthetic and give the main diver a little mental rest at least for a few minutes while they move them through that canal or drier section. So yeah, we fasted six kids on the first morning but then it became clear that actually we only had four facemasks which were suitable, so two of the kids were a bit disappointed on the first day that only four were going to go out. So we sent the first four off on the first day.
DH: And how did you secure them to the main diver?
RH: Each child was dressed in a wetsuit, full facemask, a scuba cylinder strapped to their front, which would make them float in the prone position.
DH: Like a sort of keel.
RH: Yeah. They had a buoyancy collar around them so the diver could inflate that with a little bit of air and just get them neutrally buoyant in the water so it would make them much easier to handle as they were pushed out of the cave, and so I would anaesthetise the child, they’d come down to the water, sit on my lap and I’d give them the anaesthetic. Once they were asleep, which was surprisingly quick actually, five minutes, then we put the full facemask on them, I tested it a couple of times under the water to make sure it wasn’t leaking and they were breathing adequately, and then the British diver would set off with them and take them out.
DH: Did you put any flippers on them?
RH: No. they were just bare feet, bare hands, as I say the wet suits weren’t very tightly fitting and we secured their arms down by their sides and their feet together as well, just to make them nice and streamlined so that they wouldn’t get entangled in the cave. And if they did start to wake up and wriggle a bit again we didn’t want to endanger the rescue diver, so that would give them a bit of time to get the next dose of ketamine into them.
DH: And each of them had roughly three top-ups, did they? Two or three did you say?
RH: Yeah, I think it worked out between two and four. I did lose track a little bit of exactly how much each one topped up.
"Look, if you think they’re waking up, just give them another dose"
DH: What was the indication for giving the top-up that you told the divers?
RH: So as you know, with ketamine it’s quite hard to judge the level of anaesthesia, often their eyes are open and they might be moaning or muttering to themselves a little bit, but rather than getting into the subtle signs of ketamine anaesthesia, I just told the guys, ‘Look, if you think they’re waking up, just give them another dose,’ ‘cause it’s very hard to overdose them and my priority was that the divers weren’t endangered. So sometimes they would wait until they were physically writhing around and trying to push the mask off or something, but I think sometimes the kids were given ketamine probably a bit early just because their eyes were open and they were talking a little bit or moaning, but didn’t seem to cause any great problems.
DH: So then you came out again after the four, did you?
RH: Yeah, so after the first four divers came out I said goodbye to the remaining kids, and the four Thai divers and said ‘See you tomorrow.’
DH: Did you have any indication at that stage that any of them had died or got there safely?
RH: No. I didn’t –
DH: I thought you said that the first support diver came back and told you –
RH: Yeah, so I didn’t know whether they had all survived the whole trip until I got out of the cave at the end of the night, but for that first day we set up a system where one of the British divers would swim in from the chamber 8, which was the next chamber down, would swim back in to let me know that the first one or two kids had got through at least that first dive successfully, and so that did happen and it gave me the courage to go on.
"I didn’t know whether they had all survived the whole trip until I got out of the cave at the end of the night."
DH: I don’t know what … I won’t ask you what you’d have done if it hadn’t.
RH: Well, I actually don’t know what I would … I had said to all the divers, ‘Look, if the first couple of kids don’t survive that first dive, I don’t think I can keep doing this.’ So I’m glad it didn’t come to that, because if we’d left those kids, they would have died, there’s no question in my mind, so I suspect we would have had to go back the next day and try and change something in our technique and just try again.
DH: So anyway, you got out and you found that the first four had survived.
RH: Yep.
DH: You must have been fairly pleased about that!
RH: I was, but you know what, actually I was more frightened that night than I was before the first day, because I felt it was so … unlikely that this was going to work, that I just had this terrible sense of dread that even though the first four had got out alive, surely the next day they would all die. I just couldn’t believe it was gonna work, honestly! I just … it just seemed such an outrageously dangerous thing to be doing to these kids.
So that second night, or the night before the second day, was actually the worst night for me. I just had a terrible feeling that it was all gonna go pear-shaped the next day.
"So that second night, or the night before the second day, was actually the worst night for me. I just had a terrible feeling that it was all gonna go pear-shaped the next day."
DH: But it didn’t.
RH: No. So we repeated the same thing essentially the next day and that was successful. And then the third day of course we had five people to bring out, so we had to decide whether we were going to try for five in one go or leave one behind and do a fourth day.
Every day it had been raining and the pumps were only just holding back the water, and of course the British, who had seen the force of the water early on, knew how dangerous the cave could be if it flooded again, and they were very nervous on the third day, they were very experienced in those sorts of caves and Rick in particular said, ‘It’s been raining and I reckon this cave’s gonna flood any minute basically.’ So we decided on that third day that there were some measuring sticks throughout the cave, we decided that if the cave even went up 1 cm we were going to turn around and come out, because the risk of a flood pulse coming through the cave was so high.
But it didn’t, so we got to the kids and the divers on the last day and as I say, we had decided we were gonna try for all five, but we only had four of the really good masks, so we took two other masks with us, one different commercial diving mask which did have positive pressure but it was really large, and one small, very recreational mask which wasn’t positive pressure and really looked like a bit of a toy. It was a bit of a gimmicky sort of a thing, but it was much smaller.
So we did the first four kids and including the coach, and then the last kid came down, and we had the very big mask and the tiny toy mask, and he was 29 kilos, he was the smallest of all, and I thought we’d done all the smaller kids, and then this tiny little thing comes down the mudslide, and I thought ‘bloody hell, these masks aren’t gonna fit this guy’. And sure enough gave him the anaesthetic and then tried the big commercial diving mask on and you could put your hand down the side of it. It was just no way. So we had to make this little plastic pink toy thing fit, and it was really soft and it didn’t seem to be sitting properly.
DH: With no positive pressure?
RH: No positive pressure. We fiddled round with it for about half an hour, me and Jason, one of the British guys, and I said in the end, ‘We’re either gonna wake him up again and come back tomorrow or we just go,’ so we decided to risk it and send him out. It was a pretty stressful journey for Jason and it was OK obviously, it worked, but only just I think.
DH: And then you came out last, did you?
RH: Yeah, so then of course we realised, I only realised the day before that these Thai navy guys didn’t have enough gas to come out, so we’d been bringing tanks in the day before and that day, and so I said to the Thai guys, ‘Look, give us two hours to go and then you guys follow’ because to be honest I didn’t really wanna be anywhere near them as they were coming out, ‘cause they were still at significant risk themselves and I knew they’d come out all together in a little group, so I just wanted to be well away from them. So I asked them to give us a couple of hours, so we left, or I left and swam out with a couple of the other guys, and –
The last child
DH: This was shortly after the last child, was it?
RH: After the last child, yeah, I basically put my gear on and followed out. And I was just about all the way out to the entrance when I came across one of the British divers in one of the canals all by himself just before the last dive, which was actually the most difficult dive, and he looked as white as a sheet and he seemed very pleased to see me, and I said, ‘Oh, is everything alright, is the kid alright?’ And he said, ‘Yeah, the kid’s fine, it’s me. I’ve had a bit of a near miss.’ And as he was diving through that last sump with the child he had lost the line and swum around for about 15 minutes, lost, in this pitch black water, unable to see anything, and finally ended up coming back into the cave, into the opposite direction, turned himself around, and the kid was starting to wake up and he was in a real state. So I said, ‘OK, we re-anaesthetise the child, you sit here and just take some time to get your stuff back together and I’ll take the kid out.’
So that was the only time I’d actually taken one of the kids under water and I’d chosen the worst sump to do it through, and I lost the line at exactly the same point that he did, because there was this very difficult section where the line was right out as far as you could stretch your arm out to the left in what we call a line trap, which means the rope goes somewhere that’s too skinny for a person to follow it, so you’ve gotta pull the line out of it and then feel all the way over to your right to find the hole that’s big enough for you to get through.
"I lost the line at exactly the same point that he did, because there was this very difficult section where the line was right out as far as you could stretch your arm out to the left in what we call a line trap, which means the rope goes somewhere that’s too skinny for a person to follow it."
This is all in zero visibility whilst having a kid under your arm. So in the process of not losing the kid and not losing the rope, I list the rope in exactly the same spot that this other guy had done, but it took me about three minutes to find it again, but boy it gives you a fright! ‘cause you know, you’ve only got so much gas with you, and you’ve got a kid who’s gonna wake up at some point.
DH: This wasn’t the child with the toy mask, it was …
RH: No, in fact that guy had overtaken this guy at some point, I think maybe unbeknownst to each other, I’m not sure.
DH: So you got out.
RH: Yeah, so anyway I got the experience of at least ferrying one of the kids out, which I’m sort of glad I did because it was nice to have that experience with the kid, but I could have done without the little bit of excitement in the middle.
DH: And what was your reaction at the end of the whole thing?
RH: So I stuck my head up out of the water and there’s, immediately surrounded by the US air force guys, the para-rescue team, who are amazing blokes and they’re all paramedics, very highly trained special forces medics, so they just whisked the kid away and take him out the last 500 metres of dry cave, and they’re all slapping me on the back saying, ‘Well done doc, that’s it. All done. They’re all out. They’re all alive.’ And I can’t really describe how I felt. I was sort of so exhausted I think, I didn’t really have anything left for emotions at that point, but yeah, it was a good feeling later on.
International recognition
DH: And you then found that you were internationally recognised!
RH: Well … yeah. So I’d been ringing my wife each evening, just to tell her I was safe at the end of each day, and she started to sort of hint at the fact that some stuff was appearing in the newspaper and that I’d been on the front page of the local paper one day and she said, ‘There’s a bit of excitement growing about this thing.’ We still really had no concept of the global size of the story until I got home I think, and there’s reporters everywhere and …
DH: So you weren’t bombarded by the press in Thailand?
RH: There was a huge press contingent there, but we were defended from them by the Australian Federal Police, they seemed to keep them at bay for us, and the consular people. So I had a sense that there was a story, but I didn’t realise how big … I mean for the British divers obviously the story was huge here, for myself and Craig, the story was very big in Australia, but we didn’t realise the global scale of the interest. So it was good.
A reunion with the Wild Boars
DH: Did you fly home straight away, next day?
RH: No, we had three more days in Thailand. We got to go to Chiang Rai Hospital and see the kids in the ward the next day, Craig and I, which was brilliant. We were quite privileged to do that. I think because I was the doctor I sort of asked to see my patients and they said, ‘Oh … OK, we’ll take him to the hospital.’ So we were very lucky.
DH: What sort of state were they in then?
RH: They were fine! I mean kids are so resilient! They were sitting in bed munching into their food and –
DH: Pleased to see you I should think, were they?
RH: Yeah, they were, but they were so busy eating, they could barely look up!
DH: Have you seen them since?
RH: No, I haven’t and hopefully going back next year to visit which will be good.
DH: Did you meet the Prime Minister and things like that afterwards or did they all ignore you then?
RH: No, no, we were pretty popular in Thailand for that couple of days. We met a lot of people! The Prime Minister did come up to the cave but I was …. getting organised for a dive or something when he came up, but we met the King’s representative who gave us a nice certificate and a few ceremonial sort of things, but mainly it was great just to have a beer with all the other rescuers and the divers and just unwind for a couple of days. They looked after us very well for a couple of days there.
DH: I bet you were glad to get home though, weren’t you?
RH: Yeah, it was nice to get home. And then I thought I can just come home, get back to work and this will all be just a great adventure I can put behind me, but clearly that was never gonna be the case because the story just seemed to get bigger and bigger and then the press really went to town in Australia and it’s been fairly frantic since actually.
DH: And what do your family make of it all?
RH: Well they’re very proud of me I’m sure.
DH: I bet your wife was a bit frightened during that stage?
RH: She wasn’t worried about me … in terms of my physical danger, ‘cause she knew I’d be careful in the cave and I was telling her that it was well within my abilities in terms of the diving and things, but she was very worried about the psychological impact on me if one of the kids had died, I think, so … and I’m glad I didn’t have to put that to the test ‘cause I don’t know if I’d be robust enough to deal with that if it had all gone wrong.
DH: And you’ve got three children, haven’t you?
RH: Yeah, I’ve got three, two boys and a girl.
DH: How old are they?
RH: 22, 21 and 18.
DH: So they were old enough to understand what was going on.
RH: Yeah. They think it’s all pretty cool now I think.
DH: Cool father image, is it?
RH: Yeah, that’s right!
DH: Do you think it’ll have a psychological effect on the kids themselves?
RH: I strongly believe that kids are incredibly robust and resilient and if they’re allowed to get on with their lives again they’ll be absolutely fine. There’s been so much talk about the impact on these kids and what this’ll be like, and I don’t think they … I think we underestimate the resilience of children. What does worry me is the way they’ve been very closely managed since. I mean they’re huge personalities and celebrities now in Thailand, and they’ve just been on this world tour including coming to Britain to visit, and I’m worried that at some stage they’re just gonna get dropped back into their village and that’s when it’s all gonna fall apart for them. So look, I hope they’ll be alright, and I think they should be alright as long as they’re left to get back to their families and friends at some stage.
"I strongly believe that kids are incredibly robust and resilient and if they’re allowed to get on with their lives again they’ll be absolutely fine."
DH: And you’re a fairly quiet guy yourself, as I understand. This is all unexpected publicity for you, isn’t it?
RH: Yeah, and –
DH: How are you coping with it?
RH: It hasn’t been entirely welcome, I have to say. I don’t really go out of my way to … pursue a media career. I found it all pretty overwhelming to start with, but I’m getting used to it, and look, getting an award like the one I received from the Association here today, I found that quite emotional because it’s just being recognised I think by your peers for doing something like this is much more important to me than … a medal from the government or something nice in the newspaper. I’m very proud of the fact that I was an anaesthetist involved in this. I think it’s been really good for our specialty. I think for a long time anaesthetists have been the quiet achievers in the operating theatre and elsewhere in the hospital, and I think good anaesthetists don’t court fame and fortune; we’re happy with our own lot in life. We know that we do an excellent job and that patients are very much safer because of us, and surgery is able to proceed because of us, and good surgeons recognise our skills and value our skills. But we don’t need to be patted on the back often and told how great we are, but it doesn’t do any harm for our specialty to get a bit of a boost occasionally and if this has helped with that, then that’s something I’m very happy with.
DH: Well Richard, I’m absolutely delighted that the Association of Anaesthetists has awarded you with a Pask Medal today. A very brave man himself, Edgar Pask, and you, I think, are a very, very worthy recipient of the Pask Award, so thank you very much for sparing the time to have a chat with me. It’s been absolutely fascinating.
RH: Thank you David