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“Breathe. Breathe, Karen, breathe.” I chanted these words in my head as I took my first breath with a scuba regulator during the initial day of my open water dive certification. To my profound relief, it actually worked, and I was fine.

I have always wanted to become scuba-certified, but fear always got the best of me. This dread was further exacerbated at the tender age of nine when my parents, both avid divers, went on a dive trip. When they came home a week early, I learned that the reason for their return was secondary to a horrific dive accident from which my mother suffered.

On their trip to the Pacific, my mom was caught in a downward current that inhibited her ability to normally ascend to the surface, and she ran out of air! Since her tank was out of air, she could not breathe in; however, she could exhale on her ascent, and that vital step saved her life. For reasons of prophylaxis, she spent hours in a hyperbaric chamber. Retrospectively, this was a near-drowning, hypoxic event. I am so thankful that she survived.

Twenty-two years later, I decided it was time to get over my fears of scuba diving. After taking a scuba course, I put faith in my dive master, I took my first breath underwater, I made my first descent, and I completed my first dive!

In the years between my mother’s dive accident and my own scuba certification, I trained as an emergency medicine (EM) resident in Detroit and subsequently moved to Florida when I became an attending physician. EM has its “bread and butter” chief complaints. Florida has been interesting, as my medical cases now include beach near-drownings, fishhook injuries, jellyfish stings, and various other marine envenomations. Most interesting of all these marine-related injuries are the two that crossed my chart rack in the past few months.

In a matter of two weeks, I had two separate patients with severe injuries from scuba diving. They had similar presentations, and were secondary to breaking the number one rule of scuba diving: ALWAYS BREATHE. Each patient was a young man who was scuba-certified, but each held his breath on ascent.

Both men presented with dyspnea, throat tightness, and anxiety. Although both had clear and equal breath sounds on auscultation, they also presented with subcutaneous emphysema throughout their upper chests and neck.

I knew that something horrific had happened … and I told myself, “Breathe, Karen, breathe.” It was my responsibility to take care of these patients and provide emergency care.

On spiral computed tomography scan, both had extensive pneumomediastinum. As I was considering interventions, I wondered if I would take them from their scuba respirators to hospital respirators. Despite a consultation for hyperbaric therapy, it was decided that “diving” them could possibly cause more harm. Ultimately, both men went to the intensive care unit for days of observation; they eventually self-absorbed their subcutaneous air and were discharged.

During my open-water dives, I remembered my mother and these two patients. I thought to myself, “follow the rules and always breathe … inhale and exhale.” And not only was I safe, but I saw a world teeming with life—fish, marine mammals, and plants—all with their own natural self-contained underwater breathing apparatus. It was amazing; I breathed underwater ….

The same lessons I have learned underwater and through my EM training still apply: remembering to take a deep breath and letting out a big exhale is sometimes all that is necessary to manage and survive a tough situation.