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Despite its role in ALS and inclusion in paramedic‐level protocols for over 4 decades, the clinical benefit of ETI in the prehospital environment is unclear [3–6]. ETI is associated with several risks, including failed intubation, unrecognized esophageal intubation, hypoxia, hypotension, bradycardia, aspiration, and airway trauma. While the risks of ETI can be mitigated through proper education and equipment, prehospital systems are often unable to make the substantial investments necessary to ensure a high degree of airway management safety. EMS medical directors must be prepared to properly educate and train their personnel in ETI, ensuring that they have the decision‐making and psychomotor skills necessary to perform the procedure. Many EMS medical directors believe that airway management training must include a minimum of didactic training on the indications, contraindications, and techniques for ETI, and simulated and live intubations in supervised environments.

The EMS medical director must determine how to provide suitable training for and adequate current competency in ETI. Strategies may include defining a minimum number of yearly ETI experiences, focused training with simulation, and supervised experience in the operating room or emergency department. Dashboards summarizing training and clinical airway management experience can help to identify clinicians in need of additional training. In order to concentrate limited field experience opportunities, it may be appropriate to restrict the procedure to fewer people. When available, review of video laryngoscopy images may provide key learning opportunities [7].

ETI adjuncts such as the tracheal introducer (gum elastic bougie) and video laryngoscopy may improve intubation success but at the cost of added complexity. The latter point deserves emphasis. Each newly acquired airway device increases the burden of skill maintenance. If an adjunct is deployed, the EMS medical director should consider using the device on every intubation to facilitate integration and improve skill maintenance.