The Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete recommends the face mask be removed immediately when the decision is made to transport an athlete with a suspected spine injury, regardless of current respiratory status, and that EMS providers not wait until the player stops breathing to begin the task of face mask removal because at that point, time becomes more critical. However, face mask removal can be a difficult task under the best of circumstances. If the athlete is in respiratory arrest, an airway must be established as soon as possible, whether the face mask has been removed or not, and endotrachial intubation, the gold standard method of securing and airway. PURPOSE: The purpose of this study was to determine whether a football helmet, face mask and/or a properly secured chin strap will interfere with the ability to perform endotrachial intubation. METHODS: Thirteen paramedics with 13.9 (± 7.6) years of experience were presented with a training manikin, and asked to ötube the patientô as quickly as possible, and with as little movement as possible. Each subject repeated the trial five different times under the following conditions: (1) with a football helmet, face mask, and chin strap (ALL), (2) with a football helmet, and face mask (HL/MS), (3) with a football helmet, and chin strap (HL/CS), (4) with a football helmet (HL), and (5) a control with no equipment (CTL). The sequence of trials was randomly selected by the subject. The investigator measured the time in seconds with a stopwatch and the subject rated his performance/skill of the task with a 10-point scale at the conclusion of each trial. Each subject used a 8.0 tube and a #4 Miller blade. Time began when the subject picked up the laryngoscope and ended when the stylet was pulled from the tube. The data were analyzed by ANOVA and are presented as means (± S.D.). RESULTS: The time data were; 138.3 (± 126.8), 112.2 (± 81.1), 82.9 (± 104.8), 84.8 (± 79.4), and 35.3 (± 26.8) s for ALL, HL/MS, HL/CS, HL, and CTL, respectively. The ratings of satisfaction were; 1.9 (± 2.3), 2.5 (± 2.0), 5.6 (± 3.2), 5.2 (± 2.0), and 6.9 (± 2.7) for ALL, HL/MS, HL/CS, HL, and CTL, respectively. There were significant differences (p < 0.05) between the trials for both time and ratings of satisfaction. Post-hoc analysis revealed significant time differences only between ALL vs. CTL, and HL/MS vs. CTL. It is extremely important to note that the subject quit in 9.2 percent of the trials, and 36.9 percent of the completed intubations were determined to be placed in the esophagus. CONCLUSION: These data clearly illustrate that endotrachial intubations are difficult and often unsuccessful in athletes wearing protective athletic equipment. Based on these data and those of our companion study, we recommend an alternate means for securing an airway in an athlete wearing protective athletic equipment.