Needle thoracostomy, the go-to technique for venting trapped gas and restoring blood flow, is a lifesaving skill, but it’s far from straightforward. From navigating anatomical challenges to avoiding critical missteps, this high-stakes procedure demands expertise and preparation. For EMS clinicians and EMS systems, mastering these skills isn’t optional—it’s essential for delivering top-tier care to the sickest patients when every second counts. This session will feature insights from an experienced EMS physician who provide medical direction for a large metropolitan, fire-based EMS system. Drawing from a diverse background that includes military service, the development of cutting-edge education and clinical guidelines, and managing a comprehensive quality improvement database, the presentation will integrate perspectives from medical examiners, radiologists, and trauma specialists. Attendees will not only deepen their individual understanding of this critical topic but also gain actionable strategies to empower EMS leaders in advancing their systems toward operational excellence.