Providing high-quality patient care in extreme and austere environments demands more than technical skill or adherence to guidelines. In mountain, maritime, aviation, and expedition settings, clinicians are required to make complex decisions with limited resources, environmental threat, prolonged timelines, and significant human factors at play. This lecture explores the core principles that underpin gold-standard patient care in extreme environments, drawing on real-world experience from mountain rescue, helicopter search and rescue, and expedition medicine. Rather than focusing on specific clinical algorithms, the session examines the foundations that allow teams to deliver safe, effective, and compassionate care when conditions are hostile, information is incomplete, and conventional systems are stretched. Key themes include: • Decision-making under environmental and cognitive load • Balancing ideal care with achievable care in austere settings • Human factors, teamwork, and leadership at the patient’s side • Risk management for rescuers while maintaining patient focus • Maintaining dignity, communication, and clinical standards in prolonged or exposed care The talk aims to provide attendees with a principle-based framework they can apply across disciplines, environments, and incident types supporting consistent, high-quality care even when conditions are far from ideal. This session is designed for clinicians, team leaders, and rescue practitioners seeking to refine their practice beyond protocols and build resilient, adaptable approaches to patient care in the world’s most challenging environments.