To Whom it May Concern,

As a paramedic with over three decades of front-line experience, I feel compelled to voice serious concern over the withdrawal of endotracheal intubation (ETI) from front-line Scottish paramedic practice. I do not accept the notion that rare cases of misplacement or skill fade justify this blanket withdrawal, especially when we have had waveform capnography for decades and standardised use of intubation adjuncts like stylets and bougies.

This is not just a professional frustration—it is a patient safety issue. Rather than dumbing down the scope of all paramedics to the level of the least experienced or remote practitioner, the response should have been: “be better at your job.” Train more. Assess more. Govern more. Cities and urban centres see higher rates of intubation, and the aggregated data does not reflect the true clinical exposure of many practitioners. This is a disheartening, retrograde move.

We, the undersigned, are calling for the reinstatement of endotracheal intubation (ETI) as a core skill available to all paramedics in front-line practice. The recent withdrawal of ETI equipment from Scottish paramedics represents, in our view, a retrograde and disproportionate response to selective data interpretations that fail to reflect modern clinical realities, urban workloads, or advances in airway adjuncts.

We do not accept the notion that skill fade or misplaced tubes justify removing this critical intervention. Instead of dumbing down to the weakest link, a professional service should prioritise training, governance, and high clinical standards. The focus should be on competency-based maintenance—not skill removal. Paramedics in urban settings often intubate more frequently than national data suggests, and they do so using modern adjuncts like bougies and waveform capnography, which mitigate the historical risks.

Scientific Evidence Summary:

Success Rates and Adjuncts:

A UK study of 605 cardiac arrest intubations by paramedics found a first-pass success rate of 81.5% and overall success of 98.35%, with minimal complications. Oglesby et al., 2022
Bougie use has been standardised in UK paramedic practice and is linked to improved success rates. One study noted first-pass success rising from 52% to 63% with bougie use. Driver et al., 2018
Capnography reduces unrecognised oesophageal intubation to nearly zero. Without it, misplacement is ~23%.Wang et al., 2018
Skill Maintenance and Safety:

A 2018 consensus by the UK College of Paramedics confirms paramedics can safely and effectively perform ETI given structured training and governance. College of Paramedics Airway Position Statement, 2018
Paramedics surveyed overwhelmingly value ETI as the ‘gold standard’ and resist its removal, citing the need for enhanced—not reduced—training. Moule et al., 2015
Cost Implications:

The UK Airways-2 trial found no cost advantage in removing ETI, as supraglottic devices also incur high training and equipment costs. AIRWAYS-2 trial (2018)
International Paramedic ETI Outcomes:

A meta-analysis of 69 prehospital studies found non-physician ETI success at ~91.7% (vs. 98.8% for physicians), with strong support for use in well-trained hands. Bossers et al., 2015
In Summary: The removal of ETI from paramedic practice undermines decades of professional development, disregards modern airway management adjuncts, and lowers standards to accommodate a small minority. We urge policymakers to restore ETI access for all paramedics under a robust training and competency framework.

Please sign and share this petition if you support professional, well-governed, life-saving care in our ambulance services.