I would surely rank the nasopharyngeal airway (NPA) as one of the most under-rated / under-utilized pieces of equipment in the EMT bag of tricks. They’re useful, simple and versatile. As a group, we tend to do a pretty good job 
oxygenating our patients, but I think we drop the ball on BLS airway adjuncts.
Most of our unresponsive or semi-responsive patients should be arriving at the ER with an NPA in place. If you’re bagging a patient they should have one … maybe two NPAs in place.
They’re fast, they’re friendly, they work much better on the semi-conscious and they don’t stimulate the gag reflex quite like their cousin the oropharyngeal airway. They also stay in place better, leaving the mouth open for examination and advanced airway techniques.
I’ve often had EMTs explain that they didn’t drop a basic airway adjunct because they knew I was right around the corner and I’d be intubating. That’s a poor excuse. When I arrive on scene I’d like to see that the EMT at the head has managed the BLS airway aggressively.
So let’s bone up on our NPA skills. Once you’re comfortable with these little beauties, they only take a few seconds to drop. You don’t need to make it a big production. Grab the right size, squirt a clump of KY on the end and go.
So let’s break it down and make you an NPA, quick draw, master.
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Big biker dude strained against the double layers on tape across his forehead and it occurred to me that the act of c-spine seemed pointless if the patient insisted on fighting violently against the tape and straps. Three firefighters were still holding big biker dude (BBD) down and the firefighter closest to his head was yelling, “calm down. … CALM DOWN!” This wasn’t working, but I understood. Sometimes the urge is irrisistible. For his part, big biker yelled back in disorganized consonants and vowels, “uaaaaghhh”.
BBD had laid his Harley down just before an intersection at the corner of our district. Medic units from three
different providers would be responding to the intersection to establish who’s patient he really was. This was often a recipe for conflict, but not tonight. The second medic on scene was happy to assist me with setting up IV’s and the third drove by without stopping. From his position in the road, BBD clearly wasn’t in my response area, none-the-less, big biker dude was all mine.
Maybe it was all the leather, or perhaps it was the Harley, or the time of night, but I assume from their demeanor that most folks on scene thought that big biker dude was really drunk or really mean or both. In reality he was neither. Big biker dude had a closed head injury and he was in his combative phase. Combative closed head injuries can be easily mistaken for aggressive patients by emergency responders and, if we’re not careful, the confusion can lead to incidents like this one and profoundly inappropriate care.
So what makes closed head injury patients fight us?
I found surprisingly little information addressing this specific question. While there is plenty of information to be found regarding the debate over how to treat these challenging patients, exactly why they fight is left unexamined. The reasons for combativeness are primarily theoretical. They are likely a combination of the following:
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