Heimlich's Maneuvers

by Henry J. Heimlich

  STILL UNABLE TO SWALLOW

  After replacing Hayani’s esophagus with the reversed gastric tube, I was confident we were home free. I expected that within a week or two of surgery, Hayani would be swallowing liquid and food, as my other patients had. But I was in for a disappointment. Nearly a month went by, and Hayani was still unable to swallow either liquids or solids. Every time I tried to feed him anything—even something as bland as milk or gelatin—he would gag and spit it out. We had no choice but to keep feeding him through his stomach tube.

  I was confounded. Was there something wrong with the new esophagus I had created? Was the opening between the tube and the pharynx constricted? I measured the size of the opening by passing a large rubber tube through it and discovered that it was large enough for food to pass from the mouth and into the stomach. I looked into the throat through a scope that confirmed the opening was big enough.

  I looked for other possible problems. Perhaps the nerves or muscles associated with the swallowing process were defective. If so, nothing could be done to overcome the inability to swallow food. But that was unlikely, I reasoned, since Hayani could open and close his mouth. In any case, gravity would have helped liquids to flow downward. I reviewed medical textbooks on physiologic descriptions of the swallowing process, but these provided no help.

  Then, I thought, maybe it wasn’t a case of physiology at all. Maybe the switches were all there, but Hayani didn’t know how to turn them on.

  Maybe Hayani had forgotten how to swallow.

  In the newborn infant, sucking and swallowing are reflexes that respond to visualizing food and its presence in the mouth. The tongue and lips grasp the nipple placed in the mouth, and sucking and swallowing reflexively follow. Swallowing becomes a voluntary process, then rapidly becomes a complex and essentially automatic one. But what if someone forgets this innate reflex? The answer is simple: he or she would have to be taught how to get it back. But how? I discussed with other doctors the dilemma; they simply shrugged their shoulders.

  But then the director of nursing services at Jewish Hospital gave me the answer. Nurse Isabel Weisman had previously worked in obstetrics and had spent time with newborns who did not have a sucking reflex, such as those born prematurely. When that happens, she said, it’s necessary to teach the babies this “instinct,” or they will starve. And Nurse Weisman knew just how to do that.

  “What you do,” I remember her explaining, “is you take the infant’s forefinger, put it in your mouth, and suck it. That way, the baby can feel with its finger the sucking sensation. Then you place that finger in the infant’s own mouth. Pretty soon, the infant duplicates the sucking sensation that he felt on his finger. After that, he can do it on his own.” Nurse Weisman also taught me that holding the newborn in a sitting position is the most efficient method for helping them eat because gravity helps move the food downward into the stomach.

  “You’ve made my day,” I told her and sped off to Hayani’s room.

  He was sitting in bed. A few friends were visiting. I motioned to Hayani to sit upright in a chair, which he did. Then I asked for his hand and began to suck on his finger. He and his companions must have thought I had lost my mind, but I didn’t care. I was determined to teach Hayani how to swallow.

  After I had been sucking his finger for a little while, I put that same finger in his mouth and encouraged him to replicate the sucking movements. I couldn’t tell if he was getting it, so we kept up this exercise throughout the day, and tried it again the next day, and the next. With each day that went by, Hayani’s sucking movement got stronger.

  After a week of sucking exercises, I presented Hayani with fluids and gelatin. A nurse sat with us. Hayani raised a spoonful of gelatin to his lips and put it in his mouth. He swallowed, and the gelatin went down. The nurse and I screamed with joy. Hayani smiled broadly as he experienced the act of swallowing for the first time in eight years. He took another spoonful of gelatin. Then another. And another. More smiles.

  Over the next few days, Hayani moved on to thicker foods, all served in hospital containers. One morning, as I was on my way to work, I spontaneously stopped at a grocery store and bought a chocolate-covered ice-cream bar on a stick. In my childhood, this had been the treat of all treats—the “Brown Cow” that kids begged their mothers for.

  Sitting on the bed with Hayani, I handed him the ice cream. He took it with a puzzled, slightly uneasy look and raised his eyebrows in an expression that said, “Can I?”

  I nodded, smiling. Hayani pulled off the wrapper and extracted the pop. Then, hesitantly, holding onto the stick, he raised the ice cream to his mouth, gently licked the chocolate, and took a bite. The chocolate crackled and the vanilla ice cream soon slid across his tongue and down his throat. There was no gagging, no coughing. His face lit up with the biggest smile I have ever seen. In all my years of treating patients, I do not believe I have ever felt more gratified than I did at that moment. Someone snapped a photo of the two of us smiling at each other while Hayani continued to enjoy his treat. Soon after that, Hayani’s story was written up in Medical World News; the caption that accompanied the photo read: “It’s hard to tell who is happier with Hayani’s first ice cream—Dr. Heimlich or he.”1

  RELEARNING HOW TO SPEAK

  Eating the ice cream pop was a turning point in Hayani’s life as a patient. After that, he was able to consume all kinds of foods. Because he was Muslim and could not eat pork, the hospital put him on a kosher diet. After one week, Hayani was eating voraciously.

  The next step for Hayani was enabling him to speak. This was a major challenge, given that the lye had eaten away his larynx and vocal cords, but the challenge was admirably met by a speech therapist named Patricia Reading, who taught him a technique known as esophageal speech. First, she taught him to swallow air into his stomach and then regurgitate—literally belch—the air. As the belched air passed the back of his throat and he mouthed words, he was able to clearly emit understandable guttural sounds. This made Hayani unique in the world. To my knowledge, never before had someone whose esophagus and larynx been destroyed produced esophageal speech. Before long, working with Patricia and an English tutor, Hayani could make himself understood, however haltingly, in Arabic, French, and English.

  Figure 12.2. A dear patient: My memorable “ice-cream moment” for the unforgettable Hayani.

  Hayani spent a total of about six months in Cincinnati. During that time, many of those on staff at the hospital had grown fond of him. Nurses, internists, pediatricians, radiologists, and pathologists had all participated in his care at one stage or another. When he was well enough to get around, he was invited to people’s homes, where he played with children and spent the night. I had brought him to my home numerous times. My children tell me that they remember how gentle he appeared.

  On March 25, 1971, we officially opened the Esophagus Center of the Jewish Hospital, which was devoted specifically to patients with swallowing problems. When I was handed the scissors to be used to cut the ceremonial ribbon, I looked down at Hayani and handed the scissors to him, and he proudly gave the ribbon a snip. Medical World News described the scene this way: “When it came to the question of who should cut the ribbon at the dedication of the new esophagus center, there was only one candidate. Hayani may not understand the dilatation and diagnosis that will go on in the three-bed unit or comprehend the endoscopy and motility studies that will take place. . . . But no one knows better than he what the center is for: He can swallow again, and he has friends.”2

  The day Hayani went back to Morocco, many tears were shed—tears of sorrow by those who would miss him and tears of joy for having known, admired, and loved this brave young man.

  A VISIT TO MOROCCO

  When Hayani left in March, I didn’t expect to see him ever again. But later that year, in appreciation for my efforts on the boy’s behalf, King Hassan II of Morocco invited Jane and me to visit. Before arriving in Tangier, we wondered what it was like for Hayani to be back
at the Cheshire Foundation Home after having been the focus of so much loving attention while in Cincinnati. Was he still eating and drinking? Was he still speaking?

  When Jane and I saw Hayani, he looked as happy as could be. Since he’d been back, he’d been spending time with the other children living in the home. He had also become employed at the hospital next door, working in the x-ray department.

  Observing the other children being cared for at the home was a sobering experience. Many were deformed. One young boy, whose legs were stretched rigidly out behind him, virtually “ran” around the grounds on his hands. But their joyful expressions and the good-heartedness of those who cared for them warmed our hearts.

  Jane and I brought Hayani to our hotel and treated him to lunch. We were once again charmed by his infectious smile and apparent ability to seem at home in the most unfamiliar circumstances. The hotel staff, who all knew Hayani’s story from newspaper reports, treated us grandly.

  We were pleased to see Hayani eating perfectly normally. Jane described this trip in an article she wrote for the Cincinnati Post, published on October 19, 1972: “At lunch, our first day in Tangier, my husband and I watched Hayani spear the last French fry on his plate. Except for the operative scars on his neck, our 16-year-old companion with his thatch of curly black hair, trace of a moustache, looked the picture of health.”3

  But Jane continues, “Our pleasure in seeing Hayani do justice to his meal was dimmed by the discovery that he had forgotten how to speak. Initially, our conversation centered around Hayani, but my husband and I soon began talking to one another. Suddenly, we heard a faint sob, and, turning back to Hayani, saw that he was crying.”4

  During the three days Hayani stayed with us at the hotel, I made several attempts to induce him to speak.

  “Watch what I do,” I said. I then sipped some carbonated mineral water and then burped “hel-lo,” just as Hayani had been taught in the hospital.

  “Now you try it,” I said, pouring some water in another glass. Hayani sadly shook his head. I recapped the bottle. “You’ll be talking by the time we leave,” I said cheerfully.

  On our last day in Tangier, we are having lunch with Hayani when I had an idea. ”What do you do at the hospital?”

  Hayani quickly pantomimed the click-click motion of operating the camera. “No; tell me,” I said, pointing to Hayani’s carbonated soda drink, but he sat motionless, his eyes downcast.

  “How many hours do you work?” I persisted. I put my face close to Hayani’s. “Tell me: How many hours do you work?”

  Hayani rolled his eyes helplessly. Then he took a swallow of soda. His face contorted with the struggle to speak.

  “Three,” he belched.

  I continued the questioning. “And what do you do at the hospital?”

  Another swallow. A pause. “X-ray.”

  The waiter came to take dessert orders. I smiled, remembering the success that followed his ice-cream pop in the hospital. “Will you have ice cream?” I asked. Hayani nodded. Not letting him off that easily, I said, “What kind would you like?”

  Hayani motioned for the waiter to be patient. Then, after a short while, he said, “Chocolate.”

  We spent a week in Tangier. Before we left to go back home, Jane and I visited the Cheshire Foundation Home and had one last opportunity to see Hayani. Outside the gate, we shook hands with him and several officials of the house.

  “Remember,” I said to Hayani, smiling, “if you’re coming back to Cincinnati, you must talk.” Hayani nodded and swallowed forcibly as he prepared to utter the last words he would ever say to me.

  “Good bye, Doctor.”

  Shortly after our visit, Morocco underwent a series of political upheavals that resulted in the institution of a more traditional Islamic government and the expulsion of French residents, including doctors who had been practicing there for decades. In this new environment, medical standards rapidly deteriorated, and many Moroccans, whom Western science might have saved, succumbed to disease. Tragically, Hayani was one of those individuals. I found out from one of his friends that Hayani had died of pneumonia at the age of twenty-one.

  Yet Hayani’s memory stays with me. I could never forget his calm demeanor, sense of humor, and contagious smile. And he has another legacy, too. Shortly after I helped Hayani regain his ability to swallow, I began using the same technique with other patients who also needed to relearn the act of swallowing. It was a valuable teaching method that grew out of an unforgettable ice-cream moment shared by me and one bright-eyed Moroccan teenage boy.

  Here’s a question to ponder: What do President Ronald Reagan; actors Elizabeth Taylor, Goldie Hawn, Jack Lemmon, Cher, Carrie Fisher, Ellen Barkin, Nicole Kidman and Halle Berry; basketball sportscaster Dick Vitale; famed cookbook writer Joan Nathan; Mayor Ed Koch; and newsman John Chancellor all have in common?1

  Answer: Each choked on food and were saved with something I invented called the Heimlich Maneuver.

  Many people ask me how I came up with it. Sometimes people guess that it came about by accident. Was I standing next to someone who was choking and I accidentally bumped into the person, causing the food in the throat to shoot out?

  I assure you, the process of coming up with the maneuver was much more methodical than that. In fact, I invented it just as I have all my other techniques and devices—that is, through scientific research.

  CHOKING: A SERIOUS PROBLEM

  I first became interested in the problem of choking in 1972. I was sitting in our kitchen in Cincinnati, reading an article in the New York Times Sunday magazine about accidental deaths. My wife, Jane, was in the room with me. I read aloud to her the article citing the top causes of accidental deaths. Most would be what you would expect: car accidents, fire, drowning, and falls.

  What caught my eye was the sixth leading cause of accidental death—it was choking on food or a foreign object. Nearly four thousand people were dying from choking each year in this country alone. Most commonly, people choked to death on a piece of food, or, with children, a small object they had put in their mouths. What’s more, choking was the number-one cause of accidental death in the home for children under the age of one.

  What is particularly frightening is that, when someone is choking, it takes only four minutes before the person dies or suffers permanent brain damage.

  After my many years of working to solve problems related to the esophagus, this sobering news seemed right up my alley, so I began to look into what we knew about how to save chocking victims.

  I reviewed the medical literature and learned that it discussed three different kinds of procedures. The first kind involved creating an opening in the trachea to make a temporary airway. The second required external devices used to remove the object. And the third was hitting the choking victim on the back.

  The first type of treatment involved inserting a large-caliber hypodermic needle into the trachea or performing a tracheotomy. The latter method involved making a slit in the neck, usually with a knife, to create a breathing hole in the trachea. Both of these methods were dangerous and could hardly be performed by a layperson outside of a hospital. In fact, I recall reading about a physician who tried to save his wife, who was choking, by performing a tracheotomy on her with a kitchen knife. He literally slit her throat—he cut her carotid artery—and she died of a hemorrhage.

  Some medical researchers were coming up with instruments that were designed to remove the object from the throat. There was the Throat-E-Vac, an apparatus that used suction to remove the object. One medical researcher was trying to market a pair of nine-inch-long plastic tweezers called the “choke-saver,” designed to slip down the victim’s throat and grasp the blocking food. The drawbacks of such devices are obvious: They require that such instruments be handy in the unexpected instance that a person chokes. And it would be virtually impossible for choking victims to use these devices on themselves.

  Slapping choking victims on the back was a commonly used method. Howev
er, I could find little or no scientific basis for the efficacy of back slaps. What’s more, people who were only partially choking—meaning they were still able to breathe to some extent—risked having the object be driven more deeply into the airway if they were slapped on the back.

  So my research told me what not to do if someone chokes, but what was the solution? Then I began thinking: maybe the current methods were approaching the problem from the wrong end.

  With both the tracheotomy and the back slaps, people tried to save someone from choking by doing something above the blocked airway. What about attacking the problem from below the blockage? As a thoracic surgeon, I knew there is always residual air left in the lungs, even after forcibly breathing out. When a person exhales normally, there is residual air left in the lungs that measures between 1.8 to 2.4 liters. If there was a way to make use of this air, would it be enough to expel a trapped object in an individual’s airway? I thought about how a pair of bellows works to blow air into a fire. The air is expelled when one compresses the bellows. Could a person’s lungs be compressed in the same way?

  A SUCCESSFUL EXPERIMENT

  In 1973, I decided to try to answer this question by setting up an experiment in my laboratory at Cincinnati’s Jewish Hospital, where I was the director of surgery. I used an eight-inch-long endotracheal tube with a diameter the size of a nickel and a balloon wrapped around one end. I sealed one end of the tube to prevent air from getting through and inserted it into the airway of an anaesthetized dog. I then inflated the balloon, figuring it would act like a foreign object and obstruct the dog’s airway. If I could produce a large enough flow of air by compressing the lungs, the tube should be expelled from the airway.