It is usually the most obtund and critically ill of patients that receive paramedic pre-hospital endotracheal intubation. Without a patent airway, asphyxia will lead to death rapidly if not corrected. Pre-hospital endotracheal intubation is indicated in patients when there is-or a risk of-apnoea, upper airway blockage and a need for safeguarding against aspiration due to a decreased Glasgow Coma Scale. Endotracheal intubation is currently routinely performed on cardiac arrest patients and traumatic injury patients by paramedics. However, rapid sequence intubation induction, as an advanced paramedical procedure, is not currently advocated for UK paramedic practice. Rapid sequence intubation differs from the normal method of endotracheal intubation in that it can be performed on originally conscious and/or semi-conscious patients and that it uses sedation and paralytic pharmacological agents coupled with protective airway manoeuvres to induce a state of sedation suitable to facilitate endotracheal intubation. This paper explores some of the issues surrounding whether it is feasible for paramedics to routinely perform RSI in the future.