Heimlich's Maneuvers

by Henry J. Heimlich

  One of our greatest difficulties is getting adequate supplies. We see many chest wounds that require immediate closed thoracotomy; we use bladder catheters, rectal tubes, even tubing from our suction machines to accomplish this. There is no adequate way to maintain negative pressure on these devices, and we use simple underwater seals, utilizing any type of bottle we can find.

  Last week a member of a sister surgical team out in the field sent us a small number of your No. 420098 B-D Heimlich Chest Drainage Sets. We used them immediately, and both my colleague, a Board Certified Thoracic Surgeon, and myself feel they are the answer to our problems. The few we’ve used have given uniformly good drainage, and the flutter valve attachment is perfect for our needs.3

  Dr. Baugh explained that his team was requesting a regular supply of Heimlich Chest Drain Valves from a US medical supplier, but he was so concerned of the time it would take for the devices to reach him in Vietnam that he and a colleague were willing to personally pay Becton Dickinson for them. “We’ve decided that we would be willing to purchase these tubes, and pay for them out of our salaries, so great is our need for them,” he wrote.4

  The need for the valve was so urgent that even US vice president Hubert Humphrey began to look into the matter. In a letter written to my office and dated July 14, 1966, Humphrey’s personal physician, Dr. Edgar F. Berman, said that the vice president had asked him to “investigate the utilization of Heimlich Chest Draining [sic] Valves by the Armed Forces Medical Corps in Vietnam.” Dr. Berman stated that the surgeon general’s office had noted that more than six hundred of the valves were in Vietnam and “being used for their specific purpose to good avail.”5

  But there was a problem: military bureaucracy. On November 18, 1966, the magazine Medical World News published an article titled “Medicine Battles the Odds in Vietnam,” which described in heart-wrenching detail the difficulty in saving the lives of soldiers who had been shot in the chest. The article reported that the doctors at a casualty clearing station in Da Nang, Vietnam, suffered “extreme frustration, much of it caused by acute shortages of medical supplies.” The doctors cited, as an example, the inability to get Heimlich Chest Drain Valves because the device was not on the official list of medical supplies. When the doctors placed an order for one thousand valves, it took many weeks to get it approved and then more than six months for the valves to be delivered. All the while, countless lives of wounded soldiers were lost.6

  Figure 11.2. A request from high up: When the personal physician of Vice President Hubert Humphrey asked about the Heimlich Chest Drain Valve in 1966, I knew it was badly needed in Vietnam.

  Back in the United States, Becton Dickinson was manufacturing the valves as quickly as it could, but the process was slow because the company was making them by hand. In 1964, however, the company was making use of manufacturing assembly lines to get the valves out more quickly. Still, sterilization and quality-control assessment of each valve took weeks.

  Figure 11.3. The Heimlich Chest Drain Valve: A CDV kit used by tens of thousands of soldiers during the Vietnam War and by hundreds of thousands of patients thereafter. (Photograph courtesy of Aspen Surgical and Becton Dickinson.)

  Finally, the valves were ready to be shipped to hospitals and to Vietnam. And not a minute too soon, for Becton Dickinson began to receive orders from the military for unlimited quantities. The chest drain valve was such a lifesaver that US soldiers carried them in their packs so that they could save another soldier if he was shot in the chest. And the valves were not only being used on US soldiers. One doctor noted in a letter to me that he was using the valve on Vietnamese civilians. “Their lives are as important to me as any life. We cannot get enough valves,” he wrote.

  The public was starting to read articles about this device that was saving lives on the other side of the world. I believe these stories gave soldiers and their families hope that they had a better chance of surviving combat. A 1967 article in Reader’s Digest describes the situation:

  A small device barely five inches long is saving the lives of hundreds of Vietnam wounded—civilian as well as military. Called the Heimlich Chest Drain Valve, the new device, developed by Dr. Henry Heimlich, is used to drain fluids which accumulate in the chest cavity following heart and lung surgery, during certain illnesses, or as a result of a chest wound. Failure to drain can be fatal. The traditional method of draining the chest cavity requires elaborate tubing connected to drainage bottles half-filled with water. . . . Moving the patient with this apparatus, even from one area of a hospital to another, is complicated and often dangerous. Almost insurmountable difficulties arise in combat areas, where the patient must be moved quickly and often. . . . Every soldier carried in a plastic envelope in his pocket a sterile chest tube attached to a Heimlich Valve. If he was shot in the chest, no doctor or nurse was needed. His buddy inserted the drainage tube through the bullet hole and held it in place with a strip of adhesive tape. The wounded soldier was then flown by helicopter to a base camp.7

  Yet, there were holdups. Families, military personnel, and others complained that the chest drain valves were not getting to the soldiers who needed them. While some blamed the problem on the government and military, in fact, there was such a surge in demand during wartime that the manufacturer simply could not make enough valves to meet the demand. According to Becton Dickinson, the US Army Medical Corps and the US Navy Medical Corps ordered more than twenty thousand Heimlich Chest Drain Valves for use in Vietnam between 1965 and 1968. “We produced the valves running continuously in three shifts to keep the supply flowing to the battlefront,” said Ed May in an internal company newsletter.8 Mr. May was Becton Dickinson’s product manager of its Custom and Special Instruments Division at that time.

  Since the chest drain valve was so effective in saving lives on the battlefield, I personally made sure that militaries in other countries learned how to use it. When war broke out between Israel and the Arab nations in 1967, I picked up a case of valves from Becton Dickinson and delivered them to Floyd Bennett Field, a naval air station in New York City. From there, a team of Israelis flew them to Tel Aviv.

  In 1964, I applied for a patent for the Heimlich Chest Drain Valve. The US Patent Office rejected the application, referencing previous patents for a flutter-type valve designed for other purposes. Five years later, however, the patent office changed its mind and patented the valve on August 26, 1969. At a meeting with my patent lawyer and three patent office attorneys, it was explained to us that the valve had saved so many lives, it deserved a special patent. My patent attorney said he had never seen that happen before.

  In the decades following the Vietnam War, the Heimlich Chest Drain Valve has been widely used for any condition requiring chest drainage, not just serious chest injuries and surgery. Doctors have discovered that it helps speed up recovery time and, therefore, reduces cost. Until that time, a patient whose lung had collapsed spent at least two weeks in a hospital bed hooked up to the suction apparatus. Now, when patients go to the emergency room, where a chest tube with a Heimlich valve attached is inserted into the chest, they go home immediately. Two weeks later, the patient returns to the hospital, and the tube is removed.

  Dr. Gerald Baugh, the young surgeon in Can Tho, Vietnam, who wrote the letter to Becton Dickinson and was desperate to receive the devices, remembers what it was like to practice medicine in such circumstances. When contacted at his home in Rosanky, Texas, outside Austin, Dr. Baugh explained that he and his team were trying to make do with random tubes they located, sometimes attaching the tubes to soda and beer bottles or to rubber gloves. He was grateful not only to employ the Heimlich Chest Drain Valve in Vietnam but also, after he returned, in the United States when performing chest surgery. Unlike before the device was available, when tubes coming out of a patient’s chest were connected to bottles on the floor, the patients now “could get up and walk around, so they had earlier ambulation. I think it gets them well quicker,” Dr. Baugh said.

  All told,
since I invented the device, more than four million Heimlich Chest Drain Valves have saved or improved the lives of soldiers on the battlefield as well as the lives of patients in hospitals, ambulances, and palliative-care settings at the end of life.9

  Nearly seventy years after that awful day when the Chinese soldier died in my hands at Camp Four, I think that, while I was unable to save him, his death was not in vain, for it motivated me to come up with a solution that saved the lives of so many others.

  Figure 11.4. Gratified: By the 1960s, my Heimlich Chest Drain Valve was being used to save the lives of soldiers around the world. Today, it is used both in times of war and in hospitals every day.

  In the lives of most doctors, there are those few, special patients whom we remember for the rest of our lives. Mohammed Ben Driss Hayani-Mechkouri was one such patient.

  Hayani lived very far from the city of Cincinnati, where my family and I had moved in 1968 and where I had accepted a position as director of surgery at the Jewish Hospital. He was a fourteen-year-old boy of little means and who had suffered greatly throughout his young life. By the time I met Hayani, I had helped many people who had lost the ability to swallow by performing on them the reversed gastric tube operation. And that was exactly the treatment Hayani needed.

  But his case was very different than the others. For one, it presented enormous medical challenges due to the severity of his injuries. And two, we got to know each other not only as patient and doctor, but as friends. In some ways, our relationship was like that of father and son.

  I first learned about Hayani in the summer of 1970, when I received a letter from a physician in Tangier, Morocco. He explained that Hayani was an orphan living at the Cheshire Foundation Home, a charity institution in Tangier. The Cheshire Foundation had been established by Lord Cheshire, the leading British ace in World War II who had established a string of nearly one hundred foundling homes throughout the Mediterranean area. The young residents of the Tangier facility where Hayani lived were plagued with a litany of afflictions. Some were blind; some, deaf; some, deformed. Many had been found by the Cheshire staff, abandoned in the woods, unable to be cared for by their impoverished parents.

  The doctor who wrote to me served in a mission hospital next door to the Cheshire Home and paid visit to the home from time to time. That was how he met Hayani and learned of his condition. The doctor had read about the reversed gastric tube operation and said he believed that Hayani could benefit from it.

  A DISASTROUS DRINK

  When Hayani was six years old, he suffered a terrible accident. He reached for what he thought was a bottle of soda pop, put it to his lips, and took one long, disastrous swallow of what turned out to be lye. The caustic substance destroyed his esophagus and pharynx, as well as his larynx and vocal cords. Since that time, Hayani had not been able to eat, drink, or speak.

  Doctors in Morocco had enabled Hayani to breathe better by performing a tracheotomy, inserting a metal tube through an incision into the trachea. To allow him to consume nutrition, they inserted a feeding tube through his abdomen and into his stomach, into which Hayani poured liquids several times a day. Since he could not swallow his own saliva, he frequently spit it into a cup and drooled onto his pillow at night.

  As Hayani got older, he was sent periodically to surgical specialists in the Moroccan capital of Rabat, as well as to France and England. The specialists all said the same thing: restoring normal swallowing was impossible.

  The physician who had contacted me about Hayani and I wrote back and forth for several months, during which time we discussed medical, legal, and international matters. By that time, I had been performing the reversed gastric tube operation successfully for well over a decade and had started the Dysphagia Foundation, which raised funds to care for patients afflicted with the inability to swallow. I was hopeful that these funds could be used to underwrite some of the boy’s travel and hospital expenses.

  I wrote the Moroccan doctor that yes, I would be happy to operate on the boy as soon as the necessary arrangements could be made.

  Figure 12.1. A Cincinnatian: By the time I met Hayani, I had moved my family to Cincinnati, where I was head of surgery at Jewish Hospital. (Photograph © Sarge Marsh Photo.)

  Those arrangements took the rest of the summer and half of the fall. In addition to the money that the Dysphagia Foundation donated, other organizations also contributed, including the London-based Cheshire Foundation. The US consul general in Morocco did away with much red tape and expedited Hayani’s passage to America. Air France donated two free flights for Hayani and a nurse to fly from Tangier to Cincinnati.

  HAYANI ARRIVES IN CINCINNATI

  Hayani arrived in Cincinnati around the middle of October 1970. I met him at the airport, along with a Jewish Hospital nurse, a few hospital officials, and various cameramen and reporters to whom the medical board had issued a press release. Our entourage waited on the tarmac. When the plane door opened, an emaciated, small teenager emerged, followed by the nurse who had accompanied him from Morocco. Both were smiling. When we met, the boy’s big eyes shone brightly, although he could not utter a word. Remarkably, Hayani showed no sign of being disoriented, even with all the buzz of attention.

  I got Hayani—or “Ben,” as many called him—settled into his room at the Jewish Hospital and examined him. Before any surgery could be performed, I conducted some studies to determine his general physical status, which, I was glad to discover, turned out to be pretty good. In addition, an x-ray taken of the stomach (after barium was introduced through the feeding tube) revealed that the stomach had not been severely damaged by the lye. This meant that constructing a reversed gastric tube from the stomach was surgically feasible. Yet there remained two challenges: First, his throat was severely scarred and completely closed high up into the pharynx. I would not know until we operated how challenging it would be to connect the gastric tube to the pharynx. Second, I was unsure if the feeding tube on which Hayani had been relying for many years would interfere with my forming a new, lengthy reversed gastric tube.

  During this assessment time, Hayani was well cared for. After his story appeared in the newspapers the day after he arrived, many Cincinnatians visited Hayani in the hospital and brought him enough toys to fill his room. Three members of one prominent family that lived in Tangier and were visiting relatives in Cincinnati made a generous offer. Jean Pierre Francois Joseph Pineton (the marquis de Chambrun, a descendant of the French royal family), his British wife, Bindy, and his sister Marta, Princess Ruspoli of Italy, contacted me after they read about Hayani. Princess Ruspoli explained to me that she and her brother spoke Arabic and would visit Hayani each day. I was thrilled with this idea, and so, from the many months that Hayani stayed in the hospital, one or all of the royal family members spent most every day with Hayani. They played with him and taught him to read and write English.

  I OPERATE ON HAYANI

  On October 19, 1970, Hayani was wheeled into the operating room. When I opened his abdomen, I could see that the boy’s stomach was normal in size and his feeding tube was located in such a way that it would not impede with the construction of the reversed gastric tube. Best of all, the antrum had not been damaged by the lye.

  I began to create the reversed gastric tube. Once I had the tube ready, I made a skin-deep incision in the boy’s neck. Then I created a tunnel under the skin that extended from the abdominal incision to the neck incision. The purpose of the tunnel was to run the gastric tube through it and up to the neck, thereby creating a cleaner detour free of scar tissue.

  However, I did not attempt to connect the newly created esophagus to the pharynx. There was simply too much scarring to contend with, which extended from the lower end of the pharynx all the way to the base of the tongue, the result of both the lye burns and the tracheotomy Hayani had received in Morocco. The final phase of the procedure would need to be done in a second operation. So I closed off the upper end of the gastric tube, ran it through the tunnel under th
e skin to the incision in the neck. I left Hayani’s feeding tube in place; it would be removed once Hayani was eating normally.

  The entire procedure took eight hours. During this time, I was standing, hunched over the operating table. In my early years of surgery, I did not take breaks. Sometimes a nurse would bring me a glass of milk or juice that she held up as I drank through a straw. I wanted to keep going, completely focused on my work. (Years later, I learned that it was important to take breaks, and so I would stop operating and eat a sandwich and drink a glass of milk in the surgeons’ lounge, then return to the patient wearing a new, sterile gown and rubber gloves.)

  On January 7, 1971, three months after Hayani had recuperated from his first operation, he was brought back to the operating room. This time, I was assisted by a prominent ear, nose, and throat surgeon (or otolaryngologist). I reopened the skin incision in the boy’s neck, exposing the upper portion of the gastric tube. I was pleased to find that it had healed well.

  I opened the upper end of the tube. Then I delicately cut away the scar tissue in the neck area and sewed the end of the tube to the pharynx opening. This was the highest point in the throat to which I had ever connected a reversed gastric tube. Fortunately, the tube stretched easily to the required point. This second operation took about three hours. A few weeks later, Hayani underwent a third operation, during which I removed more scar tissue. The reversed gastric tube was now in place. All that was needed was for Hayani to heal and for him to try to swallow.