The Underwater Mindset in Emergency Surgery.

Emergency surgery requires decision-making in environments characterized by uncertainty, evolving conditions, and narrowing margins of safety. Scuba diving presents similar challenges, requiring continuous reassessment of the environment, individual capacity, equipment, and team while preserving sufficient reserve to respond to unexpected events. This Surgical Reflection uses the underwater environment as a conceptual framework to explore adaptive expertise in emergency surgery. Three interconnected capabilities are considered: maintaining situational awareness beyond the immediate technical task, preserving cognitive reserve and team function as workload increases, and recognizing when persistence should give way to a change in strategy. The underwater mindset reframes adaptation-including conversion, damage-control approaches, seeking additional expertise, or abandoning an unsafe operative plan-not as failure, but as an expression of surgical judgment. In dynamic high-risk environments, expertise may ultimately depend not only on the ability to proceed, but on recognizing when the conditions that justified the original plan have changed.