Patients requiring continued resuscitation or those with concern for hypothermia may require more advanced prehospital care which cannot be delivered by typical bystanders such as definitive airway management, supplemental oxygen or mechanical ventilatory support, gastric decompression, or thermal insulation.11,15 Aggressive resuscitation attempts should be initiated unless clear signs of death or as limited by operational requirements. Patients have survived prolonged submersion historically, especially in the hypothermic environment.13 For this level of care, use the typical ABCDE format below.