How many intubations does it take to stay good at intubation?

Author: Kaleb Lachenicht, Chief Clinical Officer of ROCKET and Director Epic EM

That is an uncomfortable question for prehospital systems.

There are times when I read an article and I immediately understand the kind of impact that it is going to have on the real world, this article is one of those for me - it immediately made me shift uncomfortably in my seat... Because the questions it asks are relevant, real and when I think about it - very much going to cause some discomfort for the whole system of EMS in SA...

Not because we do not value airway excellence, but because many of our highest-stakes procedures are also our lowest-frequency procedures, and I think we tend to overvalue our experience when it comes to these challenging cases. The very interventions that matter most are often the ones we get the fewest real chances to perform.

A newly accepted South African paper on prehospital intubation puts this tension into sharp focus. Looking at intubations performed in a public EMS system, the authors found something that many of us working in EMS and HEMS will recognise intuitively: years on the register did not meaningfully predict first-pass success, but actual procedure exposure did.

The question behind the paper

The study reviewed prehospital intubations performed in Western Cape Government Health and Wellness EMS between January 2022 and December 2023. Out of more than 530,000 primary case activations, there were 236 analysed intubations performed by 40 practitioners. The overall first-pass success rate was 80.9%. Practitioner experience ranged from 0 to 14 years, while exposure ranged from 1 to 55 intubations per practitioner.

First of all... FINALLY some SA data!

That matters because we often speak about competence as though time automatically creates mastery.

But time does not intubate patients.

Exposure does. And more importantly- current exposure

The signal from this paper is not that experience is irrelevant. It is that experience without sufficient procedural volume may not be enough for a high-acuity, technically demanding intervention like prehospital endotracheal intubation.

Procedure exposure had a statistically significant association with first-pass success, while years of clinical experience did not.

Why this feels so familiar in retrieval and EMS

Anyone who has worked in a high-performance prehospital environment knows this problem.

We credential people for rare but critical procedures. We expect them to deliver under pressure, in poor lighting, with difficult access, incomplete information, physiological instability, and often a moving platform or a chaotic roadside scene. Then, depending on the system, they may only get a small number of true intubation opportunities in a year. and wonder why we are not as good as we should be.

That is not a criticism of clinicians. It is a systems reality.

This paper is valuable because it separates two things that are often lazily bundled together:

• Clinical experience

• Procedure exposure

Those are not the same thing. A practitioner may be very experienced in EMS, in decision-making, in scene leadership, in resuscitation, and in critical care thinking, while still having relatively low recent exposure to laryngoscopy and tube placement. This study suggests that, for first-pass success, that distinction matters.

The deeper leadership lesson around intubation

For me, the most important message here is not only about intubation.

It is about how we think about competence in high-risk systems. Too often, organisations reassure themselves with broad labels:

• “Senior clinician.”

• “Been doing this for years.”

• “Very experienced.”

• “Knows the job.”

All of those things may be true. But in procedural care, competence is task-specific, context-specific, and exposure-sensitive.

Personally this really holds true for me, over the last couple of months I have taken a clinical back seat in the name of business and team development. A year ago , I was as clinically sharp and relevant as I ever have been, and I was comfortable that there was nothing clinical that I could engage with that I would not manage.

Today after 8 months of more desk-based work, engaging in deifiers and learning, in teaching and business development, I am SURE that this is no longer the case. A looming night shift at a busy HEMS base awaits me this evening, and I will be only too happy to be guided in the clinical approach by my far more currently experienced team mate.

We have to be open to the fact that experience waxes and wanes, and so does our competence.

That means leaders cannot rely on professional seniority alone as proof of readiness for every advanced intervention. We have to ask harder questions:

• How often does this person actually perform the procedure?

• How recent was their last exposure?

• What does their performance data show?

• What deliberate practice structures exist between real cases?

• How are we identifying drift before it becomes patient harm?

That is a much more honest conversation. It is also a much safer one.

A few findings worth sitting with

Several aspects of the paper stand out.

First, the overall first-pass success rate of 80.9% is neither a reason for self-congratulation nor a reason for despair. It is a real-world number from a real-world public EMS environment. The authors note that prehospital FPS rates in the literature vary widely, and they position their findings within the realities of a non-physician-led South African system.

Second, the paper found that practitioners with 0 to 3 years of experience had one of the highest first-pass success rates at 83.33%. That feels counterintuitive at first glance, but it should probably make us think rather than react. It may reflect more recent training, closer adherence to contemporary technique, or other contextual factors. What it definitely does is challenge the lazy assumption that “older equals better” in every procedural domain.

Third, difficult airway was strongly associated with first-pass failure, and night-time intubations were also linked with higher failure risk. That should surprise nobody who actually does this work, but it is useful to see it quantified. Environments matter. Physiology matters. Conditions matter. Skill never exists in isolation from context.

What this means for training

The traditional approach to procedural competence often has three weak points:

1. We overvalue initial qualification

Being signed off once is not the same as staying current forever. The paper highlights that in South Africa, ECPs are deemed competent through undergraduate simulation and supervised practice, but there is no internship before independent registration. That puts even more weight on what happens after qualification.

2. We undervalue exposure maintenance

This study’s core message is that maintaining airway skill is not just about years worked. It is about opportunities to perform, rehearse, review, and refine. Systems should ensure minimum exposure thresholds and supportive structures for low-volume practitioners.

3. We mistake confidence for currency

A clinician can feel comfortable and still be procedurally rusty. In airway management, the consequences of that mismatch can be profound.

For educators and service leaders, this should push us toward a more deliberate model of airway currency:

• procedure logs that are actually reviewed

• targeted simulation for low-frequency clinicians

• focused case review, not just attendance-based CPD

• supervised refreshers where live exposure is limited

• quality assurance that is developmental, not purely punitive

The systems issue we do not like talking about

Here is the uncomfortable part.

If a system gives clinicians responsibility for high-stakes procedures but does not provide enough volume, structured retraining, performance review, or alternative maintenance pathways, then the problem is not a “people problem.” It is a system design problem.

This is especially relevant in retrieval medicine and advanced EMS. We pride ourselves on capability, but capability on paper is not the same as capability under pressure. If exposure is a determinant of performance, then leaders have a responsibility to design systems that account for exposure variability rather than ignoring it.

That may mean:

• concentrating advanced airway opportunities in selected teams

• creating rotational exposure pathways

• using operating theatre or ICU partnerships

• introducing more rigorous recency standards

• accepting that not every advanced intervention should be distributed identically across every practitioner forever

Those are not easy conversations. But they must be had

Why this extends beyond the airway

The authors make an important point in their conclusion: these principles may apply beyond intubation to other high-stakes, low-frequency procedures in prehospital care.

There is the broader lesson.

Think about:

• surgical airways

• finger thoracostomy/needle decompression

• pacing

• vasopressor infusions in transit

• complex ventilator management

• neonatal critical care interventions

  
  

In each of these, a qualification alone is not enough. What matters is the combination of:

• initial training

• exposure

• rehearsal

• quality review

• reflective practice

• system support

That is how technical excellence is built. Not by hope. Not by hierarchy. Not by seniority alone.

A note of caution

This is an important paper, but it is not the final word.

It is retrospective, from a single public EMS system, and patient outcomes were not measured. The authors also note incomplete data, the concentration of intubation volume in two practitioners working in specialised units, and the exclusion of neonatal and paediatric patients. So we should not overclaim from it.

But we cannot ignore it.

Because even with those limitations, the central message is credible, practical, and highly relevant to services like ours: exposure matters.

At the end of the day, this paper challenges one of the most common assumptions in procedural medicine: that years of experience automatically translate into better intubation performance.

This was not shown to be true here...

What showed a meaningful association with first-pass success was procedure exposure.

For EMS, retrieval, and critical care leaders, that should prompt a shift in thinking:

• We should stop treating “experienced” and “current” as though they are the same thing.

• We should design airway governance around exposure, recency, and performance review.

• We should build systems that support clinicians in maintaining rare but critical skills.

• We should apply the same thinking to all high-risk, low-frequency procedures.

Because in the end, airway excellence is not just about who your clinicians are.

It is also about what your system allows them to keep practicing well.

What this will likely change in my system? We will be looking more carefully and more closely at a structured approach to ongoing training and skill retention, within the teams, using peer driven processes and opportunities rather than a top-down approach.

How does your service think about procedural currency for rare but high-stakes interventions?

Reference

Brown, J., Abdullah, N. and Sobuwa, S. (2026) ‘Intubation exposure associated with first-pass success – understanding practitioner-related characteristics in South African EMS’, International Journal of Emergency Medicine. doi: 10.1186/s12245-026-01183-4.