Every day, hundreds of thousands of patients seek care in emergency rooms, and between 10 and 12 percent of these patients arrive by ambulance. Of these, only a few present with life-threatening emergencies requiring immediate or permanent endotracheal intubation. This is not to say that intubation is an unimportant skill, quite the opposite. Without a patent airway, most humans will succumb to anoxia in 4-6 minutes. Why then has prehospital endotracheal intubation become so controversial? In the 1850s, doctors developed methods to visualize the vocal cords of living patients and then intubate the trachea with a metal tube. Prior to these developments, protecting a patient's airway involved surgical techniques such as tracheotomy, a procedure dating back to 3600 BC (1). Since then, numerous advances have been made, including improved techniques, improved laryngoscope blade design, and, more recently, video laryngoscopy. Any improvement should drive better performance, but medical professionals continue to struggle with this skill. Over forty years ago, largely due to Accidental Death and Disability: Modern Society's Neglected Disease, the role of paramedic was created. This publication, also known as “The White Book,” documented the lack of training and standardization in the field of public safety. “This standardization led to the first nationally recognized curriculum for EMS – Emergency Medical Technician-Ambulance (EMT-A) – which was published in 1969. Many consider this document to be the birth of the modern EMS” (2). Several years later, due to the belief that more could be done in the field of pre-hospital emergency care, the curriculum of paramedics was bo... half of the document... scientific evidence against pre-hospital ETI which is by moving it away from EMS practice. It is simply the failure to adequately educate students in the use of the [endotracheal] airway. Although practice with mannequins and human simulation is improving, the need to learn this skill on human subjects remains” (6). If prehospital endotracheal intubation is to remain a viable skill, paramedics must learn, practice, and maintain proficiency in this rarely used practice. but a skill of great value. Certainly, alternative airways are a viable response, but there are still situations where the endotracheal tube remains superior. “A survey of paramedics ranked ETI as the most important [skill]. Therefore, attempts to limit or remove this ability [sic] are often met with an emotional response” (6). Paramedics must remain objective and embrace positive change for our profession to thrive.