A number of studies have shown that patients undergoing endotracheal intubation in a prehospital setting have worse outcomes than similarly injured or critically ill patients intubated in the emergency department. There has been speculation that this may be because paramedics have low intubation success and safety rates. Paramedics, particularly those in rural areas, have few opportunities for intubation; similarly trained paramedics and nursing transport teams who intubate more frequently have better success and safety profiles. The overall objective of the present proposal is to assess whether medical simulation can enhance the safety and proficiency profile of paramedics performing prehospital endotracheal intubation, and whether feedback from an airway management expert observing the simulation enhances skill retention after 12 and 24 months. Since no validated proficiency assessment tool currently exists to measure the skill of paramedics in airway management, one will be developed and tested. Using this tool, 500 paramedics in south central Pennsylvania, in primarily rural counties, will undergo simulation training similar to that require for certification. A baseline assessment of proficiency will be obtained. One group will be randomized to receive simulation training similar to that required for certification, while the othr group will receive feedback from an airway management expert linked to the simulation test site via a 2-way audio-video feed. Both groups of paramedics will be reassessed at 12-, and 24 months to determine whether skill level was maintained or whether skills deteriorated, and whether expert intervention had any impact on skill retention.