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Thai Cave Rescue: What was the impact of being trapped underground?

11 July 2018

In 2018, a junior association football team became trapped in the Tham Luang Nang Non cave system in Thailand, after heavy rainfall flooded part of the caves and blocked their way out. Due to the multiple dangers present, a rescue team of ninety divers worked to rescue the football team.

Following the successful rescue operation, World Extreme Medicine and expedition medic Dr Alex Rowe and WEM founder Mark Hannaford explained the impact of being trapped underground and the challenges those trapped in the Thai cave rescue would have faced.

What were the main dangers faced by those trapped in the cave?

When we look back at the challenges faced by these children, with the lack of safe water, and also the lack of food, it can be split into 2 things. The main risk to their health would have been with the water and risk of infection which would cause diarrhoea and potentially quite serious dehydration. The food aspect wasn’t quite so important, and they should be able to make a full recovery from the lack of food.

What impact could lower oxygen levels in the cave have had?

If the reduction in oxygen is gradual, then actually the human body could adapt to that. If the oxygen levels were reducing they would have got symptoms that are similar to altitude illness, such as headaches, nausea and a reduction in appetite. If there was a more rapid reduction in oxygen concentration they could go on to develop lung complications and brain complications as well, but at present, this doesn’t look to be the case. 

There would have also been another issue with the gases in there, in particular, the increased levels of carbon dioxide. There would have been a risk that it would gradually build up in the body, and again make you feel nauseous, it would make you flush, it would make you feel hot and eventually, it would probably make you feel drowsy and eventually would cause unconsciousness.

What did the doctors do to help those trapped in the cave?

The longer anyone is trapped, the worse their bodies will become, so their muscles will be wasting, they’ll be getting weaker over time, and the important thing here is to actually make sure they have the right nutrition. So, they will need a good amount of protein and a good amount of carbohydrates; really the usual balanced diet. Ideally, you would want to be using the muscles as much as you can, but the downside of that is if you start using muscles and doing active exercise that then increases the amount of oxygen you need.

How does a long period in the dark affect people?

The main issue with being in the dark is actually total lack of time perception, and also you tend to lose your normal body rhythms as well. So normal circadian rhythms are lost, and your body can’t really cope with that. And then in terms of the eyes as well, interestingly over time, especially in pitch black, the eyes stop being able to respond to light. It makes the eyes incredibly sensitive when people leave any prolonged dark environment. However, that is reversible.

Will their bodies be able to recover?

The physical problems are probably recoverable unless they received any severe injuries during the rescue attempt and even those can be rehabilitated. But, in terms of the physical aspect, that should all be rebuildable with rehabilitation and a good diet.

The teammates have now been reunited in the main hospital in Chiang Rai city and are said to be in quarantine for the time being while they are closely monitored, receive vaccinations for rabies and tetanus and build up their strength.

Thongchai Lertwilairattanapong, an inspector for Thailand’s health department, told reporters: “From our assessment, they are in good condition and not stressed. The children were well taken care of in the cave. Most of the boys lost an average of 2 kg in weight during their time trapped in the cave.”

What is refeeding syndrome?

We were very fortunate to have the input of Karen Allsopp, a Specialist ICU Dietitian in Macclesfield, to discuss what refeeding syndrome is and the effects of the condition.

‘You asked at what point the boys’ metabolisms will be now.  If they’ve had very few calories so far, then they’ll still be in the starvation stage – where the body adapts by minimising insulin levels, and running with low blood glucose levels and adjusting renal excretion of electrolytes down to a minimum.

Once calories are introduced – which for hospital patients in the first instance is often as iv dextrose – the levels of insulin rise quite abruptly – especially if the calorie input is high. Blood glucose levels will rise, sometimes to above 8 mmol/L even in non-diabetics. This shift to anabolism, drives movement of potassium, magnesium and phosphate from the blood into the intracellular space. This can result in hypo-kalaemia/magnesaemia/phosphataemia with potentially serious consequences.

The introduction of carbohydrates can also ‘use up’ the last remaining supply in the body of thiamine, tipping the patient over into acute thiamine deficiency. If not treated by administration of thiamine within a few hours, the neurological effects can include permanent nystagmus and permanent loss of short term memory. 

This Wernicke-Korsakoff syndrome of course is most often seen in the West in patients with alcohol dependency – but can also occur following starvation during the refeeding phase. A fascinating example is as mentioned, Dr James Scott who was lost in the Himalayas for around 40 days and wrote up his experience in the Annals of Internal Medicine. He started off with a higher BMI than the boy’.

Please see many references on refeeding syndrome: e.g…/pdf/2013-7036.pdf &… – see point 1.4.6.


Mark Hannaford Managing Director & Founder of World Extreme Medicine added:
“In a world seemingly striven by differences and polarity this rescue was a superb example of international collaboration and teamwork. 

It had us all, from start to finish, on the edge-of-our-seats from the initial finding of the boys by the amazing divers from the British Cave Rescue Council to the final safe extraction by a diverse collection of specialists from the Thai military to an international cohort of special cave divers.

Amongst the celebrations, we set aside a moment to remember the selfless heroism of Saman Gunan, a rescue diver who sadly died in the process of the rescue operations.” Tragically, a year later, another diver involved in the rescue, Beirut Pakbara, also died from a blood infection acquired during the rescue operation. 

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