Orlando Rivera

We used to high-five in the ER bay when we brought someone in with a pulse. “We got ROSC,” we’d say. Like that was the goal. Like that meant we won. But the older I get, the more I realize I’m not even sure what a “save” means anymore. The Tube Went In. The Heart Came Back. So Why Did It Feel Wrong? I still remember the call. Late shift. Cardiac arrest. Elderly female. We did everything textbook—compressions, drugs, tube, monitor, pacing, the whole dance. She came back on the monitor. We had a rhythm. ROSC.

EMS culture suffers when promotion pipelines reward protocol perfection over field leadership. The medic who knows the streets, earns peer respect, and keeps calm under fire often gets overlooked for advancement in favor of those who check every box and ruffle no feathers. It’s time we ask: who are we really promoting and why? We spend years building street-ready medics: We train them in grit, calm under pressure, and field judgment.

Editor’s Note: This manuscript originally appeared on EMS Airway. Prehospital airway management has become more than a clinical procedure; it’s become a symbol. But when the tube becomes a trophy, patients pay the price. A growing body of evidence from 2024 and 2025 challenges the status quo, urging EMS to recalibrate its airway priorities.