Two expert, healthy, male rock-climbers (26- and 31-years-old) were caught by a hailstorm in the late afternoon of a summer day at an altitude of 2800m on the vertical wall of Marmolada, Dolomites, Italy. The ambient temperature rapidly dropped to ~0°C and the older climber was directly exposed to an iced waterfall while he was secured on the vertical wall. His younger companion called the local helicopter emergency medical system (HEMS) at 7.20 pm and he was able to reach the 31-year-old patient and covered him with a mountain sleeping bag. He was already unconscious, cyanotic, shivering and with a non perceptible cardiac and respiratory activity. No CPR was performed on the vertical wall by the young rock-climber.A physician-staffed helicopter (EC-145T2, Airbus Helicopters, Marignane, France) arrived at the scene at 7.42PM and evacuated the patient with a 30-m winch operation. The helicopter landed at a mountain hut nearby and unloaded the patient who was found to be pulseless.Resuscitation maneuvers started at 7.48 pm by the medical doctor of the HEMS team. The initial rhythm was a low-voltage ventricular fibrillation refractory to three electrical shocks (200J biphasic). A mechanical chest compression device (LUCAS2; Physio- Control, Lund, Sweden) was applied after one cycle of manual CPR (120 sec.). After the third electrical shock, 1 mg of epinephrine was administered (IV) and endotracheal intubation was performed. Tcore, was 26°C (oesophageal), and initial end-tidal CO2 (etCO2) ranged between 14 and 22 mmHg. The helicopter took off at 8.20 pm and transferred the patient to the spoke Hospital of Belluno, Italy (43 km), as a direct flight to the hub Hospital of Treviso was impossible due to the darkness. At hospital arrival, Tcore was 26.6°C and etCO2 was 22 mmHg (8.34 pm). Under ongoing mechanical CPR, the patient was then transported to the hub hospital by road ambulance (83 km).During the transport the patient remain in a low-voltage Ventricular Fibrillation(VF). After arrival (11 PM), venous-arterial (VA) Extracorporeal Membrane Oxygenation (ECMO) was started (11.30 PM). At 4.30 AM, a Tcore (oesophageal) of 32 °C was reached and the cardiac rhythm turned from asystole to ventricular fibrillation. After one electrical shock (200J biphasic), ventricular fibrillation was converted into sinus rhythm and return of spontaneous circulation (ROSC) was achieved after 8hrs 42min of cardiac arrest. On day 21, the patient was extubated; CPC score was 1 with only mild retrograde amnesia at day 28. After three 3 months and 10 days from the accident, the patient left the rehabilitation ward with a Barthel Index score of 85/100, plus a Berg Balance Scaler score of 54/56 with only a minimal impairment of short-term verbal memory.