For those of us who have worked in emergency medical care settings for several years, perhaps even longer, we have all seen some version of the scenario. A physician, paramedic, or rapid response team encounters a sick patient and before long someone says that we need to intubate in order to “protect the airway.” Sometimes that is exactly what the patient needs. Sometimes the indication is considerably less clear. Many of us have also watched an apparently stable situation become substantially less stable during or immediately after intubation, with hypotension, hypoxemia, difficult ventilation, aspiration, a difficult airway, or a procedure that simply took considerably longer than anticipated.
Rapid sequence intubation (RSI) is an extraordinary tool. There are patients alive today because a clinician recognized that an airway was failing, acted decisively, and secured it. There are also patients for whom an endotracheal tube was unquestionably inevitable, and delaying it would only have made the eventual airway more difficult. This article is not an argument against RSI, nor is it an argument that BLS airway management is somehow inherently superior to an advanced airway. The question is more fundamental: when does the patient actually benefit from being intubated, and when are we performing a technically impressive intervention because it feels more definitive than what we were already doing?
That distinction becomes particularly important outside the controlled environment of an emergency department or intensive care unit. On a wildland fire, wilderness rescue, prolonged extrication, remote roadway, or disaster deployment, every intervention has an operational cost. RSI does not end when the tube passes the cords. In many ways, that is when the work begins.
What COVID Actually Taught Us
Those of us who worked through the COVID-19 pandemic watched airway management evolve in real time. Early in 2020, there was substantial concern about delaying intubation in severely hypoxemic patients. Clinicians were dealing with a new disease, uncertain aerosol risks, frightening oxygen saturations, rapidly deteriorating patients, and limited evidence. Early intubation was advocated in some settings partly because clinicians feared that waiting would result in an uncontrolled emergency airway later.
Then clinical experience accumulated.
High-flow nasal cannula became increasingly familiar. Awake proning became common. Noninvasive respiratory support was reconsidered. Clinicians became more comfortable tolerating hypoxemia in patients who were otherwise maintaining ventilation, mentation, and respiratory effort. Perhaps most importantly, the decision to intubate increasingly became based on the whole patient rather than an isolated oxygen saturation or fear of what might happen next.
Research that followed complicated the original assumption that earlier was necessarily better. A 2021 systematic review and meta-analysis involving 8,944 critically ill COVID-19 patients found no statistically significant mortality difference between early and later intubation. The authors concluded that the available evidence could justify a “wait-and-see” approach in appropriately selected patients, potentially avoiding some intubations altogether. (Papoutsi et al., Critical Care, 2021)
Another systematic review examining studies from the early pandemic similarly found no significant difference in mortality between patients intubated early and those intubated later. (Chong et al., 2022) Subsequent meta-analyses have not produced a perfectly uniform answer. Some later analyses suggested small advantages associated with earlier intubation in certain populations, while others continued to find no significant mortality difference. The evidence therefore does not support the simplistic conclusion that early intubation was bad any more than it supports the earlier assumption that early intubation was automatically good.
What COVID forced many of us to reconsider was the idea of prophylactic intubation as an endpoint in itself. A patient does not benefit merely because an endotracheal tube has been successfully placed. The patient benefits if securing that airway improves oxygenation or ventilation, prevents a foreseeable airway catastrophe, facilitates necessary treatment, or otherwise produces an advantage greater than the risks introduced by the procedure.
That sounds obvious when written on paper. In practice, it can be surprisingly easy to forget.
The Tube Is Not the Treatment
One of the phrases that has always made me pause is “protect the airway.” It can describe a perfectly legitimate indication, but it can also become a phrase that substitutes for explaining the actual physiology we are trying to correct.
Protect it from what?
Is the patient actively vomiting and unable to manage secretions? Are protective reflexes absent? Is there progressive airway edema? Is there severe facial or airway trauma that is likely to worsen? Is the patient failing ventilation despite appropriate support? Is oxygenation failing despite aggressive noninvasive measures? Is the patient’s neurologic condition deteriorating to the point that continued airway control is no longer reliable?
These are meaningful questions.
The National Association of EMS Physicians recognizes drug-assisted airway management as an appropriate EMS capability, but notably does not describe it as something that should simply be available everywhere and used liberally. Its position statement says these programs require clear clinical guidelines, adequate resources, substantial training, physician oversight, appropriate patient selection, preoxygenation, physiologic optimization, rescue-airway capability, waveform capnography, post-intubation management, and continuous quality improvement. (Jarvis et al., Prehospital Emergency Care, 2022)
That is a considerably larger undertaking than carrying etomidate, ketamine, rocuronium, and a laryngoscope.
Once we paralyze a patient, we have assumed responsibility for something the patient’s body was previously doing on its own. We are now responsible for oxygenation, ventilation, airway protection, sedation, analgesia, tube security, capnography, hemodynamics, and recognition of complications. If our ventilation is inappropriate, our newly “protected” airway can become part of the patient’s problem.
That matters tremendously in traumatic brain injury. Contemporary multicenter data involving nearly 15,000 patients with TBI found that prehospital hypoxia and hypotension were each associated with approximately twice the risk of emergency-department death after adjustment, while hypocarbia among patients with advanced airway management was also associated with poor outcomes. (Maiga et al., JAMA Network Open, 2025) Earlier research has similarly struggled to demonstrate a simple outcome advantage from prehospital intubation in TBI despite the obvious importance of preventing hypoxia. The lesson is not that severe TBI patients should never be intubated. The lesson is that placing the tube is only useful if we successfully manage the physiology around it.
A beautifully placed endotracheal tube accompanied by hypotension, prolonged hypoxia, or inappropriate ventilation is not a victory.
Now Move That Patient Off a Mountain
This becomes even more complicated in wilderness and remote medicine.
I still get asked on wildland fires, “You have RSI capabilities, right?” My answer is yes, absolutely. Depending on the assignment, medical direction, jurisdiction, equipment, and applicable protocol, advanced airway capability may be available. But in my head, another question immediately follows: what exactly are we expecting RSI to accomplish out here?
There are absolutely remote patients who may benefit from it. A patient with progressive airway burns and worsening edema during a genuinely prolonged evacuation may eventually become extraordinarily difficult or impossible to intubate. A patient with catastrophic facial trauma who cannot maintain oxygenation or ventilation may require definitive airway control. A profoundly altered patient who is repeatedly aspirating and cannot be adequately oxygenated or ventilated with simpler methods may require an advanced airway. Severe respiratory failure refractory to reasonable noninvasive support may leave no good alternative. There are also circumstances where prolonged transport makes early control of a clearly failing airway preferable to waiting for it to become a crash airway halfway through the evacuation.
Those are precisely the situations where having RSI in the tool belt matters. But now consider the other side.
You are two miles down a steep trail. The patient is breathing spontaneously, oxygenating adequately with basic support, and maintaining their airway, but has a depressed mental status. Extrication is already difficult. Once you administer a paralytic and place an endotracheal tube, somebody now has to ventilate that patient continuously while the team packages, carries, lowers, raises, or otherwise moves them through terrain. The tube has to remain secured. Capnography has to remain visible. Oxygen has to last. Suction has to remain available. Sedation and analgesia have to continue. Blood pressure has to be monitored and treated. The team must be ready for tube displacement, equipment failure, vomiting, bronchospasm, pneumothorax, or deterioration.
You have not simply solved an airway problem. You may have created an entire critical-care transport problem in an environment poorly suited to critical-care transport. That does not make the decision wrong. It means the threshold should reflect the environment.
Sometimes BLS Is the More Advanced Decision
EMS has always had an understandable attraction to procedures. Procedures are tangible. We can teach them, test them, credential them, document them, and count successful attempts. They are also satisfying. There is an undeniable feeling of having accomplished something when a difficult airway is successfully secured.
But sophisticated medicine sometimes means choosing not to perform the sophisticated procedure.
If a patient can be effectively oxygenated and ventilated with positioning, suction, airway adjuncts, bag-mask ventilation, CPAP, high-flow oxygen, or an appropriate supraglottic airway, those options deserve serious consideration. NAEMSP specifically recognizes supraglottic airways as legitimate primary or secondary EMS airway interventions and advises that when an SGA is functioning properly, clinicians generally should not convert it to an endotracheal tube merely for the sake of doing so. The decision should depend on the patient’s condition, the effectiveness of ventilation, and the clinical context. (NAEMSP, 2022)
That is an important principle well beyond SGAs: if what you are doing is effectively supporting the patient, ask what additional benefit the next intervention actually provides.
Pain management deserves similar consideration in remote trauma. A severely injured patient who is frightened, hurting, combative because of pain, and difficult to package may not necessarily have an airway problem. Treating pain, splinting injuries, correcting hypoxia, controlling hemorrhage, warming the patient, and getting them moving toward definitive care may accomplish far more than turning the encounter into an RSI because sedation would make extrication easier.
There is nothing primitive about good BLS care. Airway positioning, suction, effective bag-mask ventilation, oxygenation, hemorrhage control, temperature management, patient movement, and rapid identification of deterioration are the foundation underneath everything we do. ALS should add capability when the patient needs it, not replace fundamentals because advanced procedures are available.
The Clock Still Matters
Every procedure has a time cost.
In an emergency department, the time required to prepare for RSI may be relatively insignificant because the patient is already at definitive care. There are respiratory therapists, nurses, physicians, suction, monitors, ventilators, medications, imaging, laboratory testing, and additional airway expertise within feet of the bed.
The calculus is different forty-five minutes from a road.
If an intervention takes ten or fifteen minutes to prepare, preoxygenate, perform, confirm, secure, stabilize, and package afterward, those minutes need to purchase something meaningful for the patient. Sometimes they absolutely do. If a patient’s airway is progressively closing, those may be the best fifteen minutes spent during the entire rescue.
In another patient, those same fifteen minutes may simply delay movement toward a helicopter landing zone, ambulance intercept, trauma center, or surgical capability.
This is one of the oldest tensions in prehospital medicine: what should be done before transport, and what should be done while moving toward definitive care? There is no universal answer because geography matters. A five-minute urban transport and a three-hour wilderness evacuation are not the same clinical environment. Neither are a patient trapped in a vehicle, a patient being short-hauled from a canyon, and a patient sitting beside an ambulance twenty minutes from a Level I trauma center.
The intervention should serve the patient’s timeline, not interrupt it without a compelling reason.
RSI Is a System, Not a Skill
There is another uncomfortable question that every paramedic with RSI capability should be willing to ask: how often do I actually do this?
Not how many times did I intubate during paramedic school. Not how many mannequins have I intubated. Not how many years have I technically been credentialed. When was the last time I performed RSI on a real patient? When was the last time I managed a genuinely difficult airway? When was the last time I practiced failed-airway algorithms with the equipment I am carrying today?
A 2024 systematic review examining first-pass success in prehospital RSI found reported first-pass success rates ranging from 59 percent to 98 percent across included systems and emphasized that repeated attempts are associated with patient morbidity. (Hayes-Bradley et al., British Journal of Anaesthesia, 2024) That enormous range should tell us something. RSI capability written into a protocol is not the same thing as an RSI system capable of consistently performing the procedure well.
NAEMSP makes essentially the same point. Drug-assisted airway programs should exist only where there are adequate resources, training, credentialing, medical oversight, rescue techniques, physiologic monitoring, and continuous quality improvement. Individual and system performance should be evaluated rather than assumed. (Jarvis et al., 2022)
That standard becomes particularly important in low-volume and wilderness environments. If an urban paramedic working a busy system rarely intubates, how often is a seasonal fireline medic going to encounter a genuine RSI candidate? How do we maintain proficiency in a procedure that may be critically important but rarely indicated?
The answer cannot simply be, “Well, I’m allowed to do it.” Capability requires maintenance.
That means airway labs, simulation, video laryngoscopy practice, direct laryngoscopy practice where appropriate, bougie use, failed-airway drills, supraglottic rescue, surgical-airway familiarization, medication review, ventilator practice, capnography interpretation, post-intubation sedation, and scenario-based training that includes the decision not to intubate. Perhaps most importantly, it means being honest with ourselves about proficiency.
Then There Is the State Line
Wildland and disaster medicine introduce another layer of complexity because incidents do not care about state EMS regulations.
Large fires cross jurisdictions. Federal resources move between states. Ambulances, medical units, REMS teams, line medics, helicopters, and mutual-aid resources may come from entirely different regulatory environments. A clinician may be trained and credentialed for an intervention in one system while operating somewhere that regulates that intervention differently.
California is an obvious example because paramedic practice is governed through a statewide scope combined with local EMS agency policies and approved optional skills. What a paramedic may perform is therefore not determined simply by what that clinician has previously been trained to do elsewhere. Scope, local authorization, medical direction, credentialing, and the circumstances under which an optional skill is approved all matter.
That can be frustrating operationally, but the larger lesson is important. Advanced airway capability is not simply a medication pouch and an endorsement card. It exists inside a medical system.
When deploying across jurisdictions, clinicians and team leaders need to know before the emergency occurs what their actual authority is, who provides medical direction, which protocols apply, what medications and equipment are authorized, what documentation is required, and how care transitions to local EMS or aeromedical resources. The middle of a respiratory arrest is a terrible time to discover that everybody on scene had a different understanding of those answers.
What About the Helicopter?
There is also a practical question I think wilderness clinicians should ask more often: who is likely to own this airway thirty minutes from now?
If a critically ill patient on a wildland incident is being rapidly moved toward an aeromedical rendezvous, the incoming flight crew may bring more airway experience, a ventilator, additional medications, better monitoring, blood products in some systems, and an aircraft designed to transport an intubated patient. That does not mean we should delay a necessary airway waiting for the helicopter. If the patient needs an airway now, the patient needs an airway now.
But if the patient is currently oxygenating, ventilating, and protecting their airway adequately, and the flight crew is shortly going to assume care, there is nothing weak or indecisive about preserving what is working and moving.
The opposite is also true. If the patient’s trajectory strongly suggests that the airway will fail before the aircraft arrives, handing the flight crew a peri-arrest patient with a now-impossible airway because everyone was afraid to intervene is not restraint. It is delay. That is why this question cannot be reduced to “RSI good” or “RSI bad.”
The question is what this patient needs, in this environment, at this point in their illness or injury, with the resources currently available and the resources realistically coming next.
Protect the Physiology, Not Just the Airway
One of the strongest lessons from modern airway research is that successful laryngoscopy is not enough. We should be thinking about the physiologically difficult airway as much as the anatomically difficult one.
The severely hypovolemic trauma patient may arrest after induction because positive-pressure ventilation and medication effects remove what little cardiovascular compensation remained. The profoundly hypoxemic patient may desaturate catastrophically during even a technically short attempt. The acidotic patient who has been maintaining an enormous minute ventilation may deteriorate rapidly when paralysis eliminates that compensation and we fail to match it. The patient with severe TBI may suffer additional injury from hypoxia, hypotension, or inappropriate ventilation.
The procedure can be technically perfect while the resuscitation is physiologically disastrous. That is why modern prehospital airway recommendations emphasize preoxygenation, positioning, management of physiologic abnormalities, medication selection, waveform capnography, rescue strategies, and post-intubation care rather than simply whether the tube entered the trachea. (Jarvis et al., 2022)
This should also change the way we think about the phrase “failed airway.” Failure is not limited to being unable to pass a tube. If we intubate successfully but leave the patient profoundly hypotensive, inadequately sedated, hyperventilated, hypoventilated, or intermittently hypoxic during a difficult extrication, we have not necessarily improved the situation simply because the capnography waveform confirms tracheal placement.
The airway is only part of the patient. Treat the entire patient.
So, To RSI or Not To RSI?
I don’t think there is a clever answer, and that is probably the point.
RSI remains one of the most valuable tools available to appropriately trained prehospital clinicians. There are situations where I would want it available without hesitation, particularly when faced with a truly failing airway, progressive airway compromise, refractory oxygenation or ventilation failure, or a patient whose clinical trajectory makes loss of airway control reasonably foreseeable during a prolonged evacuation. But availability should not become enthusiasm for using it.
The evidence surrounding prehospital intubation has never been as simple as the procedure’s intuitive appeal. A systematic review comparing paramedic endotracheal intubation with alternative prehospital airway techniques found no clear outcome superiority among the available trials, while acknowledging substantial heterogeneity between EMS systems. (Jensen et al., CJEM, 2010) Modern position statements therefore focus heavily on systems, training, selection, rescue capability, and quality improvement rather than treating intubation as an inherently superior endpoint.
COVID gave us another reminder. We watched medicine reconsider the assumption that an airway should be secured early simply because it might eventually become necessary. Subsequent evidence did not prove that delaying intubation is always better, and later studies remain mixed, but it did reinforce something medicine periodically has to relearn: an invasive intervention should solve a problem the patient actually has.
That lesson becomes even more important in wilderness medicine, where an intervention that takes five minutes in an emergency department may fundamentally change an hour-long extrication.
My own preference is therefore to think BLS before ALS, physiology before procedure, and patient movement before performing something simply because it is available. Can I position the airway? Can I suction it? Can I oxygenate? Can I ventilate? Can I use noninvasive support? Can I manage the pain, agitation, hypothermia, hemorrhage, or other problem that is actually driving the patient’s deterioration? Can I safely move this patient toward definitive care while maintaining what is currently working? If the answer becomes no, RSI is there.
Practice it. Know your medications. Know your equipment. Know your failed-airway pathway. Know how you are going to ventilate afterward. Know how you will maintain sedation and analgesia. Know what your oxygen supply looks like three hours into an evacuation. Know how you are going to move an intubated patient through difficult terrain. Know your jurisdiction and medical direction. Most importantly, know your own proficiency well enough to recognize when the risk-benefit calculation has changed.
There is no shame in looking at an intervention you are authorized and equipped to perform and deciding that the patient does not need it yet. There is also no virtue in avoiding an advanced airway when the patient clearly does. RSI belongs in the tool belt. It should not be the first tool our hand reaches for simply because the patient looks sick.
Ultimately, the standard we should care about is not how advanced our care looked, how many procedures we performed, or whether we successfully placed a tube in the dirt. It is whether our decisions gave that patient the best reasonable chance of reaching definitive care alive and neurologically intact.
That is the measure that matters, especially to your patient.
– Benjamin F., NR-P
Sources:
– Jarvis, Jeffrey L., et al. “Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document.” Prehospital Emergency Care, vol. 26, suppl. 1, 2022, pp. 42-53.
– Papoutsi, Eleni, et al. “Effect of Timing of Intubation on Clinical Outcomes of Critically Ill Patients with COVID-19: A Systematic Review and Meta-Analysis of Non-Randomized Cohort Studies.” Critical Care, 2021.
– Chong, Wei Hua, et al. “Comparison of Clinical Characteristics and Outcomes of COVID-19 Patients Undergoing Early Versus Late Intubation from Initial Hospital Admission: A Systematic Review and Meta-Analysis.” 2022.
– Ji, Yun, et al. “Early Intubation and Clinical Outcomes in Patients with Severe COVID-19: A Systematic Review and Meta-Analysis.” 2022.
– Hayes-Bradley, Clare, 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.” British Journal of Anaesthesia, vol. 132, no. 5, 2024, pp. 918-935.
– Maiga, Amelia W., et al. “Adverse Prehospital Events and Outcomes After Traumatic Brain Injury.” JAMA Network Open, 2025.
– Jensen, Jan L., et al. “Comparison of Tracheal Intubation and Alternative Airway Techniques Performed in the Prehospital Setting by Paramedics: A Systematic Review.” CJEM, vol. 12, no. 2, 2010, pp. 135-140.
– National Association of EMS Physicians. “Prehospital Supraglottic Airways: An NAEMSP Position Statement and Resource Document.” Prehospital Emergency Care, 2022.