Photo/U.S. Fire Administration
The debate over paramedic endotracheal intubation has persisted for decades, cycling through periods of enthusiasm, restriction, and revival with each new wave of outcome data. Too often, that data has been selectively interpreted and used to validate predetermined conclusions about providers’ capabilities rather than to illuminate the complex, multifactorial reality of airway management in the field.
A closer look at the full body of evidence tells a more nuanced story, and a more useful one.
The Numbers in Context
National data drawn from more than 57,000 advanced airway management procedures shows that paramedic conventional endotracheal intubation (ETI) achieves 77% first-pass success and 89% overall success.1,2 When neuromuscular blockade is added — that is, when paramedics perform rapid sequence intubation (RSI), success rates improve to approximately 90%.1,3
Those figures are frequently cited as evidence of paramedic inadequacy. They should not be. For comparison, emergency department physicians achieve roughly 84% first-pass success and up to 99% overall success.4,5
The gap is real, but it is considerably narrower than the debate often implies. It narrows further when system-level factors are controlled.
In high-performing emergency medical services (EMS) systems with experienced providers and robust training infrastructure, paramedic outcomes approach or match physician benchmarks. An Australian study of intensive care flight paramedics demonstrated 89% first-pass success and 99% overall success using RSI.6
A large King County, Washington study of more than 7,500 paramedic intubations reported 77% first-pass and 99% overall success.7 These are not outliers; they are demonstrations of what adequate training, appropriate medications, and system investment produce.
The Field Is Not the ED
Any honest evaluation of paramedic intubation must begin with an acknowledgment that the prehospital environment imposes constraints that emergency departments do not. Analysis of failed first attempts in the field identifies the most common obstacles as: bodily fluids obstructing the laryngeal view (50%), obesity combined with confined-space positioning challenges (28%), inability to achieve optimal patient positioning (17%), and facial or spinal trauma (6%).7,8
These are not failures of skill. They are the predictable consequences of working in vehicles, on the ground, in darkness, without the ideal positioning that a hospital gurney and resuscitation bay provide.
Paramedics address these challenges systematically through upper airway suctioning (successful in 43% of second-attempt recoveries), patient repositioning (38%), bougie rescue (19%), operator change (16%), and RSI conversion (6%).7 The adaptation is real and measurable.
Why Mortality Comparisons Are Misleading
The most persistent error in the prehospital intubation literature is the direct comparison of mortality outcomes between field and ED intubations without adequate adjustment for case mix. The patients paramedics intubate in the field are, by definition, the sickest patients, those who cannot wait. Those who make it to the ED and are intubated there represent a meaningfully different population.
A systematic review comparing prehospital to ED intubation in trauma patients found a median mortality of 48% for prehospital intubation versus 29% for ED intubation, with odds ratios nominally favoring the hospital setting.9 The authors themselves rated the overall quality of evidence as “very low” and cautioned explicitly that the mortality difference does not contradict the value of the intervention.9
A higher mortality rate among patients who are sick enough to require field intubation is expected. It is not an indictment of the procedure.
More instructive is the finding from the largest study of urgent tracheal intubation, encompassing 71,000 patients: ED-intubated patients who had required non-tracheal airway support in the field had the highest mortality of any group, higher even than those intubated prehospitally, signaling an unmet need for earlier definitive airway management, not less of it.10
The most methodologically rigorous recent contribution to this literature is a 2026 causal modeling study that used advanced statistical methods to address selection bias directly. That analysis found prehospital intubation in appropriately risk-stratified trauma patients was associated with a survival benefit of 28 additional survivors per 229 high-risk patients, representing a 12.2% absolute benefit.10
This is the direction the field’s research methodology needed to move, and the findings warrant serious attention.
Complications: A Problem Without Borders
Peri-intubation complications are neither rare nor unique to the prehospital setting. In critically ill patients intubated outside the operating room, major adverse events occur in 30–45% of cases regardless of setting.11,12 Cardiovascular instability is the most common (43%), followed by severe hypoxemia (9%) and cardiac arrest (3%).11 These rates are comparable whether intubation occurs in the field, the ED, or the ICU.
Prehospital-specific complications in one large series included esophageal intubation (29.7% of complications), oxygen desaturation (25%), and mainstem bronchus intubation (15.9%).13 Critically, difficult intubation, defined as more than two attempts, increased overall complication risk sixfold.13 This finding is consistent across settings and underscores the central importance of first-pass success as a quality metric.
It is also worth noting that the ED intubation literature has its own gaps. A 2025 ACEP Clinical Policy on airway management acknowledged insufficient evidence to make recommendations on numerous aspects of emergency department practice.14 The evidence base for prehospital airway management, while imperfect, is not uniquely deficient.
What Actually Drives Success
The evidence is consistent on this point: provider experience and training are the primary determinants of first-pass success, not provider type.1,8, 15,16
Paramedics in most U.S. systems perform approximately three intubations per year (interquartile range 1–6), yet each additional intubation in a provider’s experience is independently associated with improved success rates.15 The implication is not that paramedics lack capability; it is that the systems in which most paramedics work do not provide them with adequate procedural volume.
Modifiable protective factors for first-pass success in prehospital RSI include: experienced intubator, ongoing training, video laryngoscopy, patient elevation on a stretcher in an inclined position, bougie use, laryngeal manipulation, and neuromuscular blockade.8
Systems that invest in these elements achieve correspondingly better outcomes. In Scandinavian critical care teams, where 67% of providers had performed more than 2,500 lifetime intubations, overall success was 98.7%, first-pass success 84.5%, and the complication rate 10.9%.17
The Video Laryngoscopy Case
The implementation of video laryngoscopy in EMS systems represents one of the clearest examples of how equipment investment translates directly to improved outcomes. In one suburban EMS system with historically low intubation success rates, introduction of the King Vision video laryngoscope combined with structured training improved overall success from 65% to 92%, first-pass success from 44% to 74%, and per-attempt success from 44% to 71%.18
Video laryngoscopy is now established as an independent protective factor for first-pass success in prehospital RSI.8 For systems still debating whether to equip their providers with this technology, those numbers provide a straightforward answer.
The Right Comparison
Meta-analyses confirm that physicians outperform paramedics on aggregate intubation success (99% vs. 92% overall; 88% vs. 78% first-pass).1,19 However, the European physician-led EMS systems that anchor these comparisons are staffed primarily by anesthesiologists with thousands of intubations of career experience.1,19
Comparing a paramedic who performs three intubations per year to a procedurally experienced anesthesiologist is not a comparison of capability; it is a comparison of exposure. When physicians and paramedics are compared using the same technique under matched conditions, the gap narrows to statistical near-equivalence (99% vs. 96%).19
The question is not whether paramedics can intubate. The evidence that they can and do, effectively, is extensive. The question is whether the systems in which they work are designed to support that capability.
System Solutions, Not Provider Blame
The appropriate response to variable prehospital intubation success rates is not to restrict paramedic scope of practice. Rather, it is to build systems that support the factors we know drive success: robust initial training, procedural volume maintenance, access to RSI, video laryngoscopy implementation, and structured quality improvement programs with case review.
High-performing systems have demonstrated that paramedic intubation success rates can approach physician benchmarks when those investments are made. The gap between what EMS providers can achieve in optimized systems and what they achieve in under-resourced ones is not a gap in human potential. It is a gap in institutional commitment — and that is a gap we can close.
References
1. Crewdson K, Lockey DJ, Røislien J, Lossius HM, Rehn M. The success of pre-hospital tracheal intubation by different pre-hospital providers: a systematic literature review and meta-analysis. Crit Care. 2017;21(1):31. doi:10.1186/s13054-017-1603-7
2. Wang HE, Donnelly JP, Barton D, Jarvis JL. Assessing advanced airway management performance in a national cohort of emergency medical services agencies. Ann Emerg Med. 2018;71(5):597-607.e3. doi:10.1016/j.annemergmed.2017.12.012
3. Jarvis JL, Jarvis SE, Kennel J. The association between out-of-hospital drug-assisted airway management approach and intubation first-pass success. Ann Emerg Med. 2025;86(5):521-530. doi:10.1016/j.annemergmed.2025.04.034
4. Park L, Zeng I, Brainard A. Systematic review and meta-analysis of first-pass success rates in emergency department intubation: creating a benchmark for emergency airway care. Emerg Med Australas. 2017;29(1):40-47. doi:10.1111/1742-6723.12704
5. Brown CA, Bair AE, Pallin DJ, Walls RM. Techniques, success, and adverse events of emergency department adult intubations. Ann Emerg Med. 2015;65(4):363-370.e1. doi:10.1016/j.annemergmed.2014.10.036 (For more current benchmark data, see also: Maia IWA, Besen BAMP, Silva LOJE, et al. Peri-intubation adverse events and clinical outcomes in emergency department patients: the BARCO study. Crit Care. 2025;29(1):155. doi:10.1186/s13054-025-05392-w)
6. Delorenzo A, St Clair T, Andrew E, Bernard S, Smith K. Prehospital rapid sequence intubation by intensive care flight paramedics. Prehosp Emerg Care. 2018;22(5):595-601. doi:10.1080/10903127.2018.1426666
7. Prekker ME, Kwok H, Shin J, et al. The process of prehospital airway management: challenges and solutions during paramedic endotracheal intubation. Crit Care Med. 2014;42(6):1372-1378. doi:10.1097/CCM.0000000000000213
8. Hayes-Bradley C, McCreery M, Delorenzo A, et al. Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis. Br J Anaesth. 2024;132(5):918-935. doi:10.1016/j.bja.2024.02.004
9. Fevang E, Perkins Z, Lockey D, Jeppesen E, Lossius HM. A systematic review and meta-analysis comparing mortality in pre-hospital tracheal intubation to emergency department intubation in trauma patients. Crit Care. 2017;21(1):192. doi:10.1186/s13054-017-1787-x
10. Nelson AP, Dodds N, Zeina M, et al. Survival effect of prehospital emergency anaesthesia with intubation in risk-stratified patients with major trauma: a causal modelling study. Lancet Respir Med. 2026;14(3):256-266. doi:10.1016/S2213-2600(25)00370-4
11. Russotto V, Myatra SN, Laffey JG, et al. Intubation practices and adverse peri-intubation events in critically ill patients from 29 countries. JAMA. 2021;325(12):1164-1172. doi:10.1001/jama.2021.1727
12. Downing J, Yardi I, Ren C, et al. Prevalence of peri-intubation major adverse events among critically ill patients: a systematic review and meta-analysis. Am J Emerg Med. 2023;71:200-216. doi:10.1016/j.ajem.2023.06.046
13. Caruana E, Duchateau FX, Cornaglia C, Devaud ML, Pirracchio R. Tracheal intubation related complications in the prehospital setting. Emerg Med J. 2015;32(11):882-887. doi:10.1136/emermed-2013-203372 (For a more current risk-factor analysis with a consistent complication profile, see also: Le Bastard Q, Pès P, Leroux P, Penverne Y, Jenvrin J, Montassier E. Factors associated with tracheal intubation-related complications in the prehospital setting: a prospective multicentric cohort study. Eur J Emerg Med. 2023;30(3):163-170. doi:10.1097/MEJ.0000000000001010)
14. American College of Emergency Physicians Clinical Policies Subcommittee on Airway Management, Godwin SA, Hahn SA, et al. Clinical policy: critical issues in the management of adult patients requiring endotracheal intubation in the emergency department. Ann Emerg Med. 2025;86(2):e29-e68. doi:10.1016/j.annemergmed.2025.04.003
15. Dyson K, Bray JE, Smith K, et al. Paramedic intubation experience is associated with successful tube placement but not cardiac arrest survival. Ann Emerg Med. 2017;70(3):382-390.e1. doi:10.1016/j.annemergmed.2017.02.002
16. Reinert L, Herdtle S, Hohenstein C, Behringer W, Arrich J. Predictors for prehospital first-pass intubation success in Germany. J Clin Med. 2022;11(3):887. doi:10.3390/jcm11030887
17. Gellerfors M, Fevang E, Bäckman A, et al. Pre-hospital advanced airway management by anaesthetist and nurse anaesthetist critical care teams: a prospective observational study of 2028 pre-hospital tracheal intubations. Br J Anaesth. 2018;120(5):1103-1109. doi:10.1016/j.bja.2017.12.036
18. Jarvis JL, McClure SF, Johns D. EMS intubation improves with King Vision video laryngoscopy. Prehosp Emerg Care. 2015;19(4):482-489. doi:10.3109/10903127.2015.1005259 (For a current systematic review/meta-analysis confirming this effect across systems, see also: Kent ME, Sciavolino BM, Blickley ZJ, Pasichow SH. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the out-of-hospital environment: a systematic review and meta-analysis. Prehosp Emerg Care. 2024;28(2):221-230. doi:10.1080/10903127.2023.2219727)
19. Lossius HM, Røislien J, Lockey DJ. Patient safety in pre-hospital emergency tracheal intubation: a comprehensive meta-analysis of the intubation success rates of EMS providers. Crit Care. 2012;16(1):R24. doi:10.1186/cc11189 (For a larger, more current meta-analysis reproducing this physician vs. non-physician RSI comparison, see also: Fouché PF, Stein C, Simpson P, Carlson JN, Doi SA. Nonphysician out-of-hospital rapid sequence intubation success and adverse events: a systematic review and meta-analysis. Ann Emerg Med. 2017;70(4):449-459.e20. doi:10.1016/j.annemergmed.2017.03.026)
Stephen P. Wood is a paramedic and critical care nurse practitioner. He is a long-time contributor to JEMS and has an array of published articles and book chapters. He is the program director for the acute care NP and Extreme Medicine programs at Northeastern University. He is still active as a SWAT medic for the Quincy, MA Police Department and as the co-advisor for NU EMS.
