Crack surgical teams performed "heroic" life-saving surgeries on those badly injured in the Whakaari / White Island tragedy, with some members working up to 14 hours a day treating the victims.
And what made their efforts – described by the president of the Australian and New Zealand Burn Association (ANZBA) president Dr Jeremy Rawlins as both "phenomenal" and "heroic" - even more remarkable was the trying conditions the life-savers had to contend with in operating theatres as they battled to save lives.
As family members of the 22 who perished from injuries suffered in the December 9, 2019, eruption remember their loved ones, Rawlins has spoken of the physical and mental toll on the medical teams who both cared for patients who later died, and those who survived the tragedy with life-changing burn injuries.
"They were literally at it from 8am till 10pm every day," Perth-based Rawlins told the Herald.
"They were doing massive burn debridement, skin grafting. There was a huge physical toll on those individuals."
Most of the worst injured were airlifted to Auckland's Middlemore Hospital in the hours after they were initially rushed from White Island to Whakatāne Hospital.
Rawlins described what awaited the surgical teams and other specialists who dealt with eruption patients at Middlemore Hospital in the coming days and weeks as "exhausting work".
He said those in theatre were dealing with "big injuries, they are big patients, they have lots of bleeding ... it is really physical surgery".
Temperatures in operating theatres are normally kept at around 18C. But for burns surgery they are at 28C.
"We work in operating theatres that are very hot because our patients can't control their own temperatures," Rawlins explained.
"Patients have basically lost their skin and the skin is responsible for keeping our temperature normal. So, they can't control their own temperature. If they get really cold or hyperthermic, then all the systems don't work ... the clotting of the blood doesn't work properly, the liver doesn't work very well."
Given the temperatures the theatre staff were working in, surgeons, nurses and other team members had to regularly rehydrate to avoid dehydration during the long shifts.
What confronted them was not just physically challenging. Rawlins said it was also "very mentally draining".
"A lot of what we do in burns and plastic surgery, you take the good with the bad," he said.
"Yes, you do the 60 per cent burn [patient], but you also do the cleft lip repair on the baby and see that little baby smile, or have a breast reconstruction where you have treated someone with breast cancer. [The latter two] are happy days.
"Whereas if you spend day after day after day carving burnt tissue off someone, that plays a role on your mental health and you start to not only feel physically drained, but you start to feel mentally drained. You think, 'Gosh, when is this ever going to end?'.
"You do need a bit of a respite from this, even if it is only for half an hour. You get home at 10pm and you get a little bit of a respite from all these burns ... even just to turn the telly on and watch The Simpsons, just to get escapism from it."
Members of burn units – including surgeons, nurses and a host of therapists - who cared for the White Island injured put their lives on hold in the weeks which followed the deadly eruption.
The welfare of patients was very much the first priority, Rawlins stressed, with their care being put ahead of prior family commitments.
"It takes a certain plastic surgeon to say, 'What is really right for these patients is that we put some of our interests on hold that can be put on hold, and we commit 100 per cent to looking after these burn patients'," he said.
"And that is what my colleagues, in particular in Auckland, did."
He described the surgery, nursing and resulting therapy carried out on patients as "phenomenal, heroic and acute".
Rawlins never treated any of those so badly impacted by the White Island tragedy.
But he worked closely with and talked to ANZBA members – which includes a wide range of health professionals responsible for the care of the burn patients - on both sides of the Tasman who did.
That includes fellow plastic surgeon Dr Richard Wong She; the clinical leader of the National Burn Centre of New Zealand, which is based at Middlemore Hospital.
Rawlins said it became apparent "very quickly" after the Auckland team was alerted about the eruption on the fateful Monday afternoon that what awaited them "was going to be a really huge challenge and very different from the normal sort of burns that we look after".
"The reality of the situation was then that Auckland was going to become swamped with what were very, very difficult injuries and they would need support from A, the rest of the country, but also realising that a lot of these patients were actually from Australia, and then more sensibly would be better off treated in Australia, hopefully in the city they came from or lived."
Rawlins was involved in talks with Wong She and the New Zealand and Australian governments about the eventual repatriation of Australians badly burned in the eruption back across the Tasman for further care.
That process was made easier due to the high level of collaborations between burns units on both sides of the Tasman.
"We do a lot in terms of education and training across the two countries, so there really is no border in regards to what happens here in Australia, or in New Zealand," Rawlins said. "We teach the same emergency management and severe burns courses across those two countries."
ANZBA operates under four key pillars; research, clinical care, education and prevention.
And Rawlins said ahead of the anniversary of the tragedy, it would be "remiss" of the medical body not to address the latter in terms of trying to avoid a repeat of the horror that occurred last December.
While he said New Zealand had "amazing geographic geography" which lent itself to a raft of adventure tourism, steps needed to be taken to ensure those activities were carried out in a way that tourists weren't put in undue danger.
"When something like this happens, people invariably go, 'How can we prevent that from happening?'. If we don't ask that question then we are not serving our people, our society and our population well," he said.
"And I think that will come out in the future, how aware were these people who were on this tour of White Island that actually this was potentially a ticking time bomb in terms of sustaining a burn.
"Presumably there will be things in place to avoid people tramping over basically a live volcano so that it doesn't happen again. Those poor people who died, those poor people who are left with horrible scarring, they will want to ensure that other people don't succumb to the same thing."
Kiwi surgeons' break-through with artificial skin on White Island patients
Surgical teams at the National Burn Centre of New Zealand called on all their skill and dedication to care for many of the worst injured in the Whakaari / White Island tragedy.
And in the process of delivering in most cases life-saving treatment, the teams at the unit based at Auckland's Middlemore Hospital also employed the use of new technologies which could help with the care of future severe burns patients in New Zealand.
said that included new artificial skin products.
Given the large number of patients from White Island, and the extent of their injuries, burns surgeons in New Zealand had never used the skin substitutes in such quantities before.
The Perth-based burns treatment expert said the skins were "recent advances" in burn care that "played a huge role in improving the quality of lives of these patients who were burnt on White Island".
"These are temporary skin substitutes that we use on our patients in times when they have massive burn injuries where we don't have enough skin available to skin graft from," Rawlins told the Herald.
"Often we can put these temporary dermal matrixes on and that buys us time to keep the patient alive whilst the rest of their skin heals so we can use that as skin grafts.
"When you have these very complex patients, and some of them have huge burns, they will have definitely have been using those products and got a lot more experienced doing so. In some ways having lots of patients to deal with and having to use some of these new technologies is good because you get better at using some of these new technologies, you see how those products work well and perhaps how they don't work so well."
As well as using artificial skin substitutes, the burns teams also carried out huge amounts of grafting via skin tissue sourced both in New Zealand and via the Community Tissue Services skin bank in Ohio in the US.
Almost a month on from the December 9, 2019, eruption a quarter of a million square centimetres had been used on patients; that equates to 14 full human bodies' worth of skin.
Rawlins said the teams working on White Island patients – including surgeons, nurses, physios and other therapists – had learnt "huge amounts" from the process of caring for them.
He said the extent of the burns suffered by those on White Island were "like nothing anyone had looked after before".
"They were a combination of a blast injury, plus what is affectively a scold injury, plus a flame burn. These are really difficult injuries," he said.
"The key with good burns surgery is that you are well-trained, you have done trauma surgery, you have worked across different areas of plastic surgery and burns, so you can adapt when these happen.
"Hats off particularly to the teams in New Zealand who were looking after these patients very, very early on, that they were able to go, 'This was a bit different to what we're usually used to, but okay these are the principles that we know, and this is how we are going to manage them'."
Rawlins said given the nature of the injuries, the relationship between burns teams on both sides of the Tasman with some of the White Island patients would be "lifelong".
The Western Australian burns unit he works at still deals with patients caught up in the 2002 Bali Bombings. The terror attack killed 202 people, including 88 Australians. A further 66 Australians were among those injured.
"We still see some of these patients in our clinics," Rawlins said. "Areas of scarring become a little tighter and we have to do a bit of lasering to release some scarring.
"Some phenomenal, heroic and acute surgery, nursing and therapy happened a year ago [after White Island] but relationship and reliance on that burn service ... will be lifelong for some of these patients. They will have ongoing psychological trauma, and ongoing physical trauma, that will require little bits of ongoing surgery as the months and years go on."