VOLUME 37, ISSUE 1

Russell K. McAllister, M.D., FASA
TSA Secretary and Editor-in-Chief
Professor and Chair of Anesthesiology
Baylor Scott & White Health-Central Texas
Baylor College of Medicine -Temple
Temple, TX
Against All Odds-A review of the book detailing the Thailand soccer team cave rescue
In June of 2018, an event occurred in Thailand that caught the attention of the people all over the world. A soccer team of young teenage boys and their 25-year-old coach became trapped in a rapidly flooding cave. The book, Against All Odds brings us the story of the rescue of these boys in a most unlikely and never before attempted manner. The book’s authors, Craig Challen and Richard Harris (Harry, as he is known to those close to him), are also the main characters in the story.

The backstory begins as the soccer team and their coach decided to explore a cave that was well known to them. It was also known that, during the rainy season, this cave would flood for months at a time. However, the rainy season was not expected for several more weeks and the boys and their coach felt safe entering the cave, one they had explored numerous times in the past. After exploring about two and a half kilometers into the cave, they noted the water began to rise rapidly, cutting off their exit from the cave. In fact, in order to reach higher ground, they were forced even further into the cave. With their exit cut off, everyone understood that the rainy season was now upon them and the chances of the water receding enough for them to exit was almost zero. The boys’ bikes were discovered outside the cave and, before very long, the entire nation was searching frantically for the missing boys in the flooded cave, fearing the worst.
The authors enter the picture because of their unique skill set. Richard Harris is an anesthesiologist and Craig Challen is a recently retired veterinarian, both from Australia. They had met up with each other because of their shared love of cave diving and had been exploring caves together all over the world for the past several years. In fact, they were packing for another adventure when the story of the trapped boys became news across the world.
The authors describe the events of the ensuing 2 weeks as divers from around the world searched for and eventually located the soccer team. Experts from all over the world began to arrive on the scene to assist. Veteran British cave rescue diver, Rick Stanton, led the team that eventually navigated the 2.5 kilometers (km) dive to the cave chamber where the boys were located. He reached out to Harris and Challen (who he was familiar with from the relatively small worldwide cave diving community) and initially described the heartbreaking scene to Harris, as he asked for him and Challen to join them at the cave and assist with the rescue. Stanton stated, “I just want to warn you. You’re going to dive to the end of the cave. You’re going to see these kids. They’re all looking healthy and happy and smiley. Then, you’re going to swim away and they’re probably all going to die.”
The duo describes the moral and ethical dilemmas they faced as well as the political turmoil of the government being reluctant to allow foreigners in to assist with the rescue, especially as the plan began to unfold of how they might be able to successfully rescue the team. The authors do a great job of describing the anguish felt by the team and the dangers of the mission to provide assistance to the young boys. In fact, one member of the Thailand Navy Seals had already perished in an attempt to bring additional supplies and oxygen tanks deep into the cave. The Navy Seals were expert divers, but had little to no experience in cave diving, which is vastly different in nature. Additionally, none of the trapped boys had any diving experience, the current of the water was strong, the temperature was frigid, the visibility was zero within the murky water (despite their bright helmet lights), and the journey was 2.5 km. Even for the world’s most experienced cave divers, the path in and out of the cave was treacherous. Attempting to train and rescue a novice child diver safely through this distance of caves seemed impossible and put the boys and their rescuers in mortal danger, as panicking while underwater is a leading cause of death in cave diving situations. At many points in the exit path, the openings were so narrow that the supplemental oxygen tanks had to be removed for the rescue divers to navigate through the opening. All navigation through the flooded cave passages was done blindly via a guide rope set by the initial divers that discovered the boys, as a path back to the cave opening, in case they became disoriented in the pitch-black cavern.
It quickly becomes obvious that the options for rescuing the boys were limited. As the rainy season progressed, the cave chamber where the boys were would eventually flood. Waiting months for the rain to subside was not considered a viable option. The idea of anesthetizing the boys, fitting them with a face mask and oxygen, and diving them out under the guidance of an experienced diver was proposed and initially tossed aside as seemingly impossible. It had never been done before. Dr. Harris describes everything that went through his mind as far as things that could go wrong with such a dangerous plan. Drs. Harris and Challen were tasked with coming up with a plan on how to safely guide the young boys out of the cave through the long and treacherous path. They were asked to plan something completely unheard of. Something that had never before been done. A plan that seemed to have a high likelihood of resulting in the death of the boys, and possibly even their rescuers.
Both authors had extensive clinical anesthesia experience, Dr. Harris with humans and Dr. Challen with a wide variety of animal species. They wrestled with the ethical dilemmas of how to proceed, or if they even should proceed, with such a dangerous undertaking. How would they be viewed if they failed? Would they forever be known as the “doctors who killed those kids in Thailand?” Did they have diplomatic immunity or would they end up in jail for murder if the mission was unsuccessful? Neither had a license to practice medicine in Thailand, which was a big diplomatic problem. They had the best cave divers from all over the world, but no one else besides the authors had any medical training. How would they manage in helping transport an anesthetized patient through an underwater cave with zero medical training? If they could overcome these issues, how would they medicate the children safely with no monitoring whatsoever in a dark cavern? How would the children react? The rest of the team would watch as the first of their friends were anesthetized and taken into the exit passages of the cave. What effect would that have on how the subsequent “patients” would respond? If the boys emerged from anesthesia underwater and panicked, would they rip the mask off and drown themselves and their rescuers? How would they maintain a level of anesthesia to keep the boys safe throughout a four-hour dive journey? There was no way to communicate with the outside world. They would be sending kids into the cave’s deep tunnels without any knowledge if the children just ahead of them had survived or died. If any of the first few children died during the journey, would they abort the mission? What was the limit on how many had to die before they stopped trying? The circumstances would not have changed and the chances of death were still almost certain if nothing was done. Which is better? A death of starvation and slow drowning as the water rose or a quick drowning death while anesthetized in a narrow cave passage? These are the ethical dilemmas that the entire team were wrestling with. These thoughts are difficult to imagine but raced through the minds of the rescuers.
The authors answer all of these questions and the reader can empathize with the difficulty of all of their decisions as they do their best to devise a plan to safely rescue the soccer team and their coach. I really enjoyed the book for a variety of reasons. As an anesthesiologist, I was able to fully appreciate the complexity of their dilemma. The austere conditions within the cave provided a very dangerous situation in which to attempt any sort of sedation. The unlevel muddy ground, partially in and out of the murky water compounded the inherently unsterile and unsafe conditions. By itself, cave diving is one of the most dangerous extreme sports there is. Similar in danger to a free climb up the face of a sheer cliff. There is absolutely no room for error and the conditions are very unforgiving. The risks of anesthesia that we accept in our hospitals in the best of conditions with the best monitors and equipment can, at times, be anxiety inducing for our medical teams and our patients. The idea of performing an anesthetic in a dark dirty cave and then diving 2.5 kilometers through a cave with extremely narrow passageways, rapid currents, and zero visibility while pulling your anesthetized patient behind you along a guide rope created extreme anxiety for me, as the reader. It is difficult to imagine the amount of anxiety and uncertainty that was felt by this team of rescue divers.
Harris and Challen shared several background stories that seemed like great life lessons. Experiences that they had that uniquely prepared them for this mission. Harris noted that attitude is often an extremely important aspect of how a person approaches life. He notes, “How you react to something makes a difference. It determines if you are going to enjoy it or not. It determines whether you’re going to be any good at it.” I thought this observation was profound and it really hit home for me. How we react to adversity is a big part of our lives and can make a huge difference with how we respond during crisis management in the operating room. One of my colleagues is famous for the simple quote that he tells our trainees. He says, “Do hard things.” His point is that, if you undertake difficult tasks and seek out the most challenging patients and surgeries, it makes you a better doctor and better prepared for whatever unique adversities that you may encounter throughout your career. The attitude of the children trapped in the cave was also noted by the authors. Despite the adversity that they were faced with, the children always seemed to be in a mindset that was helpful to their rescuers. It is enlightening to read the authors’ description of the mental fortitude displayed by the trapped members of the soccer team.
Through a lifetime of preparation, these authors found themselves uniquely prepared to undertake an operation that no one else in the world was better prepared to undertake. Little did they know that such a rescue effort would arise that would require a combination of their unique talents and ingenuity. The book, Against All Odds, is a fascinating story that details the harrowing events of those rainy days deep within a Thailand cave and gives details of the mission that, I believe, anesthesiologists will find especially fascinating. I encourage everyone to read this book. It will be one that, once you get to the heart of the story, you will find it difficult to put down.