Extreme environmental hypothermia is a complication of harsh conditions encountered during mountaineering, Nordic skiing, polar exploration, scuba diving, and remote river expeditions. Its physiological complexities have only recently been fully appreciated and have generated enthusiasm for new therapies. Because patients with extreme hypothermia often appear to be lifeless, dramatic reports of survival following profound hypothermia have stimulated medical authors to support the notion that "no one is dead until warm and dead."1-4 Furthermore, most recommendations currently support therapeutic maneuvers such as extracorporeal blood warming or peritoneal dialysis, although there are no compelling data to show that survival is enhanced by these techniques.5 There is considerable expense generated by a rigorous resuscitative effort. The costs for transport, cardiopulmonary bypass, and intensive care unit habitation are acceptable only if survival advantage and reasonable hope can be demonstrated.6 Despite occasional successful efforts at reanimation, the aphorism may require modification.