To evaluate pediatric endotracheal intubations by our paramedics, we performed a retrospective review of a prehospital computer database, quality assurance reviews, and prehospital run sheets for all patients under 15 years of age who had an endotracheal tube (ETT) placed. During the 4.5-year study period, 324 pediatric patients had intubation attempts by field paramedics, of which 264 (82%) were successful and three were reported esophageal and unrecognized by the paramedic. Two of these esophageal placements were noted on arrival at the hospital, and one upon turn-over of patient care to a nurse of an aeromedical service. All three intubations were deemed esophageal with direct laryngoscopy, and the patients had been in cardiopulmonary arrest status prior to the intubation. Of the 264 patients who had ETT placed, 99% were endotracheal, while only 1% were unrecognized esophageal. We conclude that pediatric endotracheal intubation by out-of-hospital paramedics in an established EMS system has a low occurrence of unrecognized esophageal placements.