Heimlich's Maneuvers

by Henry J. Heimlich

  Once I inflated the balloon, the dog stopped breathing, signaling that he was choking. Immediately, I pressed on the dog’s chest, but the tube did not move. I tried it again. Still, the tube went nowhere. I tried it a few more times and still no results. I quickly removed the tube, and the dog began to breathe again.

  I stopped to analyze the situation. Obviously, simply pushing on the chest did not compress the lungs sufficiently. The problem was the rib cage—the rigid, bony ribs held their shape under extreme pressure. After all, from an evolutionary standpoint, that is the purpose of the ribs, to protect the body against a blow to the heart and other vital organs.

  I moved down the body in my thinking and thought about the diaphragm, the flat muscle that separates the chest from the abdomen. If I pushed the diaphragm upward into the chest, perhaps that would create the “bellows” effect and force air from the lungs upward, expelling the tube out of the dog’s throat.

  I turned back to my sleeping, canine patient, and I again inserted the tube and inflated the balloon until the dog began to choke. Then I placed my fist on the dog’s belly, just under the rib cage, and pushed the diaphragm upward into the chest.

  Instantly, the tube shot out of the animal’s mouth.

  Once I got over the shock, I repeated the procedure. I again induced choking and pushed upward on the dog’s diaphragm. Again, the tube flew out of the dog’s mouth. I tried it a few more times, and each time, I got the same result. In trying different amounts of pressure, I also discovered that this same effect was achieved even when I applied only a little bit of pressure.

  I sent my assistant down to the hospital cafeteria for a piece of meat. When he returned, I put the meat into the anesthetized animal’s windpipe, knowing I could pull it out if my method failed. I again pressed the chest (rather than the diaphragm this time) repeatedly. Nothing happened. Then I moved my hands just below the rib cage and pressed upward on the diaphragm. As with the tube, the meat shot out of the dog’s mouth. I repeated the procedure over and over. Each time, my pushes expelled the meat.

  I wondered what would happen if I applied the same pushes in the case of a partial blockage. At first, I thought the method would not work, that the object would have to be stuck tightly in the windpipe, like a champagne cork in a bottle, to allow enough pressure to build up and pop out the meat. But as I experimented, I found that the flow of air past an object only partially obstructing the trachea, like a chicken bone, was still enough to push the object upward and out of the mouth. It was the flow of air, not the amount of pressure, that carried the object away.

  I went about measuring the actual measure of airflow. Working with my fellow doctors and some hospital residents, we calculated the airflow quite easily with some simple tests. Each of us was fitted with a mouthpiece that was connected by tubing to a machine that measured the flow of air passing out of our mouths. We then let our colleagues force our diaphragms upward using their fists. Today, the results would be measured by a computer, but in our day, it was measured by a graph on a rotating drum.

  The figures were astounding. During normal breathing, a person exhales about two gallons of air per minute. But when we forced our diaphragms upward with a fist, each application of the method produced almost a quart of air in one-quarter of a second. This force of air came to almost 60 gallons of air per minute, more than enough to drive a trapped object out of the throat.

  I initially dubbed my method “sub-diaphragmatic pressure.” It would take a while before it received a catchier name.

  USING AIR IN THE LUNGS TO PUSH OUT AN OBJECT

  I had proved one important thing: pushing in and up on the diaphragm—at a point just above the navel and below the ribs—creates a flow of air from the lungs that can expel an object out of the airway. Now I just had to figure out how best to go about creating that “push.” The technique had to be simple enough so that anyone could apply it quickly. I was reminded of the scary fact that brain damage and death are only minutes away. I knew there was no time for people to depend on a household instrument to perform the “pushing” technique. What if the device was not handy at the time it was needed? Paramedics would not be of much good, since they would most likely not arrive in time to save the person’s life.

  I tossed around some ideas. What procedure would be simple enough for anyone to understand, even a child? What procedure would be easy enough for anyone to perform in any situation? I came up with several possible options. For example, a person could brace the victim’s back against a wall and push with a fist against the upper abdomen. Or a person could lay the victim on the ground and push with a hand or foot on the upper abdomen. I tried these different methods on some friends. Finally, I settled on these five simple steps:

  Stand behind the victim and reach around the person’s waist with both arms.

  Make a fist with one hand.

  Place the thumb side of your fist below the rib cage, just above the belly button.

  Grasp the fist with your other hand and press the fist inward and upward.

  Perform the technique firmly and repeat it until the choking object is dislodged from the airway.

  In addition to this basic method, I investigated how to apply the technique in different situations. For example, suppose a person faced a choking victim of such large stature that the rescuer could not reach around the victim’s waist. Suppose a small woman or a child was trying to save a large man. What would happen if the victim had lost consciousness and had fallen to the floor? Was it necessary to lift the victim to a standing position? What if he or she was too heavy?

  To plan for these contingencies, I developed an alternate, lying-down position. With the victim lying down on his back, the rescuer kneels astride the victim’s thighs, facing him. Then she places one hand on top of the other and puts the heel of the bottom hand on the same spot, just above the belly button and under the rib cage. The rescuer can use her body weight to overcome the size differential. In this way, a smaller individual could likely save a large or overweight person. Even a very young child might be able to save an adult.

  By 1974, about one year after I had begun my experiments, I believed my technique could save lives and that I had enough evidence to introduce it to the public. But I knew the clock was ticking. People were choking to death every day. Usually, the way medical solutions become popularized is by performing time-consuming studies in hopes that the findings are published in a prestigious medical journal. This could take months or years. How many people might choke to death in that time? I was anxious to educate the entire country as soon as possible.

  I decided that I would use the media to tell others about my discovery.

  GETTING THE WORD OUT

  The idea of using the press to get the word out about my antichoking method was highly unorthodox for 1974. Back then, not only did researchers tend to go the medical-journal route, but also doctors, hospitals, clinics, and drug companies did not advertise themselves and their products directly to the public as they do today. In fact, using the popular media to disseminate health information was discouraged by the medical establishment, and doctors generally considered it unethical to talk to the press.

  But I decided I would disregard the accepted attitude. Lives were at stake, and I believed that using the media was the fastest way to allow others to learn about my method and put it to use.

  I first approached Emergency Medicine, a medical journal that had published some of my previous work. I called the editor and said that I’d like him to publish an article of mine about a technique I had devised for saving the lives of choking persons, and he agreed.

  “Pop Goes the Café Coronary” appeared in Emergency Medicine in June 1974. (The term “Café Coronary” refers to the fact that people frequently choke to death while eating in a restaurant, while onlookers often mistakenly assume that the person is having a heart attack. That year, I developed what became a universal symbol for choking—holding your hand around your throat—to allow the
victim to communicate, “I’m choking.”) In the article, I make clear that my experiments had been used only on dogs. “We cannot be certain, of course, that the experimental results will be duplicated in humans,” I wrote. “Only by disseminating public information about this simple technique can we determine whether it will result in a significant reduction of what amounts to 3900 totally avoidable deaths every year.”2

  I had asked the editor of Emergency Medicine to send the article to syndicated medical columnist Arthur Snider, who had reported on my reversed gastric tube operation twenty years earlier. On June 16, 1974, Mr. Snider’s column—carrying the headline, “A New Method to Save Food-Chokers”—began appearing in hundreds of newspapers across the country.3

  One week later, this headline appeared on the front page of the Seattle Times: “News Article Helps Prevent a Choking Death.” Someone had read Mr. Snider’s column and had tried my technique on a choking person. And it had worked.

  Figures 13.1–3. The Heimlich Maneuver: There are various ways the Heimlich Maneuver can be performed, depending on the size of the victim, the size of the rescuer, and whether the victim has collapsed.

  These medical illustrations were originally created by renowned surgeon and artist Dr. Frank H. Netter.

  (Netter illustrations used with permission of Elsevier, Inc. All rights reserved. www.netterimages.com.)

  Figure 13.4. Teaching tool: As restaurants put up posters on how to do the Heimlich Maneuver, staff were able to jump into action and save lives. (Image courtesy of Deaconess Associations, Inc.)

  THE FIRST SAVE

  Isaac Piha was sitting in his cabin on Hood Canal when he read about my method in the Seattle Times. Piha was particularly interested because he was a retired restaurateur who had seen several of his patrons choke to death on pieces of meat. A few days after reading the article, Piha was enjoying a Father’s Day gathering when he heard a neighbor named Edward Bogachus calling for help. Piha and his family ran to the Bogachuses’ cabin, where they found Mrs. Bogachus slumped at the dinner table and turning blue (choking victims turn blue from a lack of oxygen in the blood).

  “I thought about heart attack and about that article in the Times while I was running to the cabin,” Piha was quoted saying. “When I saw that they’d been eating dinner, I knew it was food lodged in her throat.”4

  Piha performed my technique on Mrs. Bogachus, which dislodged a large piece of chicken from her throat, and she quickly recovered. To my knowledge, Mr. Piha is the first person to have performed on a human choking victim what later became known as the Heimlich Maneuver.

  It did not take long before I heard of another save, and another, and so on. People began saving the lives of their children, their spouses, and strangers in restaurants. Children became rescuers, too. Young people saved adults and sometimes other children. For instance, I remember reading about a four-year-old girl who saved the life of her two-year-old brother when he was choking on a piece of chicken. The boy was eating in his high chair. After he became silent and started turning blue, the girl got behind the high chair and performed the technique. A large piece of chicken skin flew out of the two-year-old’s mouth. The girl had learned the technique from watching family members practice it. (Ten years later, at a ceremony recognizing those who had saved the lives of children, I presented a letter of congratulations to the girl—by then, a teenager—and stated that she was the youngest in the world to have ever successfully used the Heimlich Maneuver to save the life of a choking victim.5)

  That life saved in Salt Lake City showed that if a four-year-old can do the technique, anyone can.

  I recall the director of medical services at the Albert Einstein Medical Center in Philadelphia telling me how his wife started choking on a chicken bone at a dinner party. The bone—one and a half inches long and pointed at both ends—did not completely block her airway. After two application of the technique, the bone flew out of the woman’s mouth. This report confirmed what my experiments had demonstrated: It was not necessary for an object to completely block the airway for the technique to work. Even an object like a bone or a toothpick, which allows a flow of air around it, can be dislodged with my method.

  WHEN THE CHOKING VICTIM IS ALONE

  The stories continued to come in. People reported saving their relatives, next-door neighbors, spouses, even pets. Then I received a letter in 1975 from Luvan Troendle, a woman in Minnesota who reported a most unusual and significant case—one that occurred years before I invented my antichoking method but that eventually led to me coming up with additional instructions for employing my technique.

  “You must have received hundreds of letters about your ‘Heimlich Hug’ but this one has a different tack,” the letter said. Troendle explained that she and her husband had been vacationing in Canada in 1959 with two other couples. One night, while she was inside a cabin with the group and her husband was outside cleaning fish, the host served up steaks. “I was trying to chew my steak which was very tough but I could not chew it into small pieces and I would not dare to spit it out so I decided to swallow it . . . but it stuck in my throat!”

  Troendle wrote that she then left the table. “I knew I could never explain to the liquor-happy diners what had happened! My only hope was to get to the door and summon my husband but when I got across the twenty feet of the cabin floor and opened the door I knew I could never call to my husband . . . and I would not be able to explain if I did get his attention. My breath was failing and I knew I could not run the fifty feet to the boat dock where he had been cleaning fish.

  “I decided to do the only thing available . . . to give myself a ‘thump’ on the back . . . so-to-speak . . . and I threw myself against the handrail of the cabin stoop. The most astonishing thing happened!!! The piece of steak flew out of my mouth and landed on the ground eight feet away! I had saved a life with this act . . . my own!”

  She went on to say that the incident taught her something important: “I could help myself . . . AND I could help someone else in a similar plight.” On the back of the letter, she had drawn a rough sketch of what happened when she saved her own life.

  Figure 13.5. Solo save: People have saved themselves from choking by performing the Heimlich Maneuver on themselves in creative ways.Luvan Troendle wrote me a letter including this sketch, describing how she saved herself. (Sketch by Luvan Troendle.)

  There were other reports of solo saves. I heard of a woman who was choking and who saved herself by pushing into her upper abdomen with her own fist, for example. (In 1983, the Journal of the American Medical Association, or JAMA, published a letter to the editor, written by a physician in Bethesda, Maryland, who stated that he had saved himself the same way. Dr. Thomas Carlile wrote that his airway was cut off by a pill. “I instinctively clasped my left wrist with my right hand and forced them vigorously into the substernal region. The tablet was forcefully expelled across the small bathroom and shattered on the lavatory mirror into a powder.”6) I soon realized that people could save themselves by finding a number of creative ways to press up on their diaphragms, such as pressing against the edge of a table, the back of a chair, the edge of a sink, or any other firm object.

  But regardless of how people chose to save others and themselves from choking, my method was working. People who would have otherwise died from choking were alive. A letter written to me on November 11, 1975, captured this feeling. It came from Frank Wicher, an attorney in Sioux City, Iowa, who was blind. Mr. Wicher explained that he and his wife were having a steak dinner at a large table with ten people present.

  “There appeared to be a little commotion across the table from me and the folks informed me that my wife was choking.” Once he realized this, Mr. Wicher “whipped around that table as fast as a man might who could see” and performed my technique on her, once, twice, three times. “The chunk of unchewed steak was ejected and she was breathing once again,” he wrote. “I know full well, Dr. Heimlich, that had I not read of your procedure I would have buri
ed my wife six months ago. . . . From the bottom of our hearts, my wife and I thank you. My six daughters thank you as do our eleven grandchildren.”

  A short time later, Mr. Wicher arranged for me to go to Sioux City, and we had lunch in the restaurant where he had saved his wife.

  MY PROCEDURE GETS A NAME

  While developing and refining the technique, I had given little thought to what it should be called. Then, two months after the first article appeared in Emergency Medicine, I received a phone call from an editor of JAMA.

  Because my procedure had saved many lives, he felt it should be given a name and that it should be named after me.

  “We don’t know whether to call it the Heimlich Method or Heimlich Maneuver,” he said. “A maneuver is something done once, or the same procedure is repeated. A method is a series of steps, like a urine analysis.”

  I did not want to spend the rest of my life explaining how my work was like a urine analysis.

  “Maneuver!” I shouted into the phone. In an August 12, 1974, editorial, JAMA editors described my procedure as the “Heimlich Maneuver.”7 It was the first time that the name was made public.

  Soon after the editorial was published, I received a letter from JAMA’s editor in chief, asking me to write an article describing my discovery. My article, “A Life-Saving Maneuver to Prevent Food-Choking,” was published in the October 1975 issue of JAMA.8 When the article appeared, there was an accompanying editorial stating that the Heimlich Maneuver had been officially endorsed by the Commission on Emergency Medical Services of the American Medical Association, the country’s foremost medical organization. The editorial stated that the maneuver is “a most important addition to the emergency care procedures for the person choking on food or other objects that shut off the airway.”9