Heimlich's Maneuvers

by Henry J. Heimlich

  THE MANEUVER GOES MAINSTREAM

  The maneuver was also catching on outside the medical community. Before I knew it, the technique was making its way into the scripts of soap operas, sitcoms, game shows, and films. Many comedians made light of how people could save a life by wrapping one’s arms around a choking victim. Movie director Woody Allen wrote a comical short story titled “A Giant Step for Mankind,” which chronicles the desperate attempts by three obscure scientists who are determined to discover a technique to save people from choking. The three experiment with water and tweezers, induce choking in mice, and seek out choking victims in restaurants.10

  I appeared on such radio and television talk programs as the Today show, Good Morning America, and, my favorite, The Tonight Show Starring Johnny Carson.

  My name and that of my technique became household words. In 1979, Life magazine published new words of the decade. One of them was Heimlich Maneuver.11 Then, shortly after the new year began, I received a copy of the Random House Dictionary from its publisher. There, on page 887, was the definition of Heimlich Maneuver.

  I was amused to discover that my name had become a verb in the American lexicon. People would say, “I did the ‘Heimlich’ on him,” or “I ‘Heimliched’ her.” The term Heimlich Maneuver was translated into countless languages such as Spanish (as Maniobra de Heimlich) and German (as Heimlich-Handgriff).

  It made me happy to see that the public was becoming more and more aware of the maneuver for one simple reason: getting the word out—to have the technique become part of our culture—increased the possibility that people would learn how to do the maneuver and use it to save lives.

  The maneuver helped to create an image of me as a doctor who was an authority in any emergency situation. In the late 1970s, I initiated discussions with the ABC network about producing a cartoon that would teach children medical first aid. The cartoon—which was to air on Saturday mornings during children’s programming—would feature me as a goofy, bald character in a white lab coat who pops up on the screen amid a medical crisis, offering advice. “HELP! Dr. Henry’s Emergency Lessons for People” became a series of six, one-minute animated segments that taught kids what to do in such emergency situations as a cut finger or drowning. In 1979, “HELP!” won an Emmy Award for best children’s show. During that time, children recognized me as “Dr. Henry,” the character who suddenly appeared in the cartoon to guide children through dealing with an emergency. In 1980, Simon and Schuster published a book called Dr. Heimlich’s Home Guide to Emergency Medical Situations. I was thrilled to cowrite the book with Lawrence Galton, the acclaimed medical writer who had written for Cosmopolitan about the case of Virginia Dixon.

  As a physician who never imagined that my work would ever catapult me into fame, it was difficult sometimes to comprehend being known to millions of people around the world. But once I accepted what was happening, I realized that I was grateful for the attention the maneuver received, for it meant that those millions of people were learning how to recognize when people were choking and how to save them.

  Figure 13.6. The maneuver, Jane, and me: Jane and I pose in a “maneuver” embrace for People magazine in 1999. (Photograph reproduced by permission from Black/Toby.)

  To this day, I continue to read articles on a daily basis of people who have been saved with the maneuver. Around Christmastime 2012, eleven-year-old Louis Fritz of Cincinnati, where I reside, saved his eight-year-old brother, Davis, when he was choking on orange slices. Louis performed the maneuver on Davis three times until the food popped out and landed on the family’s kitchen table.12 I had the honor of meeting young Louis at his school when I presented him with a Heimlich Institute Certificate of Heroism Award.

  Figure 13.7. A simple lifesaver: The Heimlich Maneuver became famous worldwide because of its simplicity and effectiveness.

  The Heimlich Maneuver became popular for one simple reason: it allows anyone—no matter how small or how old—to save a life. Furthermore, the maneuver is easy to learn, it’s easy to use, and it’s effective. Of course, there is always the possibility that well-meaning people will injure choking victims in the process of trying to save them. Injuries can occur when the maneuver is applied incorrectly, but they are often relatively minor, considering the person was saved from choking to death.

  Figure 13.8. Today: Restaurants across the United States hang a poster showing staff how to perform the Heimlich Maneuver. These posters are invaluable because servers often save the lives of choking victims. (Image courtesy of Deaconess Associations, Inc.)

  Yet, despite all the success the Heimlich Maneuver has achieved—and the thousands of lives saved—one large first-aid organization has historically rejected the technique while insisting on teaching people another method that has an abysmal track record of saving a choking person. My battle to convince this organization to correct its mistake has proven to be one of the fiercest struggles of my life.

  In 1978, a mother sued the Harrisburg, Pennsylvania, school system for not having properly trained its staff on how to save children from choking. A few years before, the woman’s son, Gary Daniels, was eating a peanut butter sandwich at school and started choking. A teacher began slapping Gary on the back. The boy continued to choke and fell unconscious. Apparently, the food was not completely blocking his windpipe, because he did not die immediately.1

  But Gary Daniels never woke up after that. Having been denied oxygen for several minutes, he suffered severe brain damage, lapsed into a coma, and died a few years later.

  I became an expert witness in the case.

  When contacted on July 19, 2013, Richard Angino, the attorney who represented Gary’s mother, said he remembered the case well because of the emotional aspect of it.

  “We were all moved by this case,” said Mr. Angino, “because this wonderful mother had taken care of her son for years at home. She deserves a place in heaven.”

  Speaking from his law office in Harrisburg, Mr. Angino remembered explaining to the jury that the school was to blame for failing to teach the staff on how to do the Heimlich Maneuver. The case was settled out of court for $325,000.

  “Nobody fought me on the fact that if the teacher had done the Heimlich Maneuver, the boy would not be in a coma,” said Mr. Angino.

  The case of Gary Daniels is not an isolated one. I have known from the time I conducted my research on the maneuver that back slaps were ineffective in expelling an object from someone’s windpipe. But I also believe that they are dangerous, based on numerous cases and studies showing that back slaps not only failed to dislodge an object but also drove an object that was partially blocking the airway deeper into the throat to the point at which the airway was then completely blocked.

  On the other hand, the Heimlich Maneuver, when performed correctly, is safe and saves lives. When I invented it in 1974, cases poured in from around the world from people who had saved someone’s life or who had had his or her own life saved. A 1985 French study showed that the maneuver could be successfully used in very young children and infants.2 It’s clear that the maneuver is the best solution for virtually any choking victim, adults and children alike.

  So I was astonished to discover that the nation’s premier first-aid organization, the American Red Cross, was teaching people to hit choking victims on the back.

  TEACHING A POTENTIALLY DANGEROUS METHOD

  The American Red Cross was founded in 1881 by medical pioneer Clara Barton; it was issued as a corporate charter by the US Congress in 1905. Under the charter, the Red Cross has three main responsibilities: (1) to fulfill the provisions of the Geneva Conventions, (2) to provide family communications and other forms of support to the US military, and (3) to maintain a system of domestic and international disaster relief, including mandated responsibilities under the National Response Framework coordinated by the Federal Emergency Management Agency (FEMA).3

  Today, the organization is a lifesaving behemoth. It has a national network of more than 769 regional o
r city chapters. It mobilizes more than one million volunteers each year and has on staff forty thousand employees to provide relief to people affected by natural disasters worldwide.4 It trains some nine million people in necessary medical skills each year5 and wields enormous influence over the distribution of medical information in the United States. Supported by donations and the sales of blood products and educational materials, the Red Cross operates on a $4.1 billion budget.6

  The Red Cross began recommending that people hit choking victims on the back in 1933. Over time, medical authorities grew to question whether back slaps were effective and safe. In 1969, the American Broncho-Esophagological Association warned that back slaps are dangerous.7 Following that advice, the Red Cross told people not to use back slaps. From 1973 to 1978, the organization stated the following in its teaching manuals: “Do not allow anyone to slap you on your back if you choke . . . except as a last, desperate effort to save his life.”8

  Then came the Heimlich Maneuver in 1974. As soon as the discovery became known, individuals began trying it, and it was not long before reports of people saving the lives of others—as well as their own lives—began to pour in. Many times, people who had witnessed the incidents described how objects “flew” out of victims’ mouths. In October 1975, the American Medical Association Commission on Emergency Medical Services endorsed the Heimlich Maneuver as “a most important addition” to other antichoking methods.9

  Meanwhile, hitting a choking victim on the back became less and less popular as the method of choice. Two years after the maneuver became known, a study published in the Journal of the American College of Emergency Physicians (JACEP) that measured airflow generated from applying pressure to various parts of the body showed that back slaps were ineffective at creating airflow—airflow that would be needed to dislodge an object caught in the windpipe. Researchers concluded, “The technique of delivering a sharp blow between the shoulder blades . . . was so ineffective in creating airflow or increased pressure within the chest, it was abandoned.”10

  Given what we knew about the effectiveness of the Heimlich Maneuver and the problems related to back slaps, one might think that the Red Cross felt justified with its decision to stop teaching the back slap. Yet in 1976, the Red Cross inexplicably changed its policies, advocating that people use both back slaps and what it called “abdominal thrusts.” By “abdominal thrust,” the organization meant the Heimlich Maneuver. The reason why they didn’t refer to the technique as such is because I refused to allow them to use my name. I knew that hitting choking victims on the back was a bad idea and didn’t want my name associated with the organization’s teachings.11 Thus, the organization came up with the term abdominal thrust. (The Red Cross has made a bad situation worse, however, by using that term because it gives the impression that one can press anywhere on the abdomen, and this has the potential to cause abdominal injuries and fail to save a choking victim.)

  WEAK EVIDENCE

  I learned about the organization’s position shift at a meeting with Red Cross and National Academy of Sciences officials in Chicago that year. Dr. Archer Gordon, who was a physician and who served as a leading advisor on choking to the Red Cross, described at the meeting two unpublished studies he had conducted that led him to conclude that back slaps effectively saved people from choking to death. Dr. Gordon explained that he had taken four anesthetized baboons, put a piece of meat in each of their throats, and hit them on the back. With that blow, he claimed, the meat had then been “loosened.”12

  In the second study, Dr. Gordon explained that he had anesthetized six human volunteers and placed pieces of meat in their throats, just as he had with the baboons. In the human study, the physician explained that he had tied a string to the meat so that it could be pulled out, if necessary. According to Dr. Gordon, back slaps were administered to the subjects, after which the meat was “loosened,” again, just as had happened with the baboons.13 Dr. Gordon, who was also the medical director of a film company, then showed a film of him carrying out this study. One subject was a middle-aged, anesthetized woman. “That’s my wife,” I remember Dr. Gordon saying. “The others wouldn’t volunteer for it unless I did the experiment on her first.”

  What Dr. Gordon failed to offer, however, were reasonable answers to numerous questions his studies raised. For example, were the results pertinent, given that the meat was merely loosened and not expelled? Can one look into a baboon’s throat—or anyone’s throat, for that matter—and detect that a piece of meat has indeed been loosened? Since anesthesia relaxes throat muscles, would the administration of anesthesia more likely explain what caused the meat to loosen?

  Red Cross officials then got into a discussion to determine just how many back slaps a rescuer should deliver to save a choking victim. Based on what I recall from the ensuing discussion, the number seemed quite arbitrary.

  “How about twelve?” someone said.

  “No; they would be dead by that time,” another official objected.

  “How about two?” someone else asked.

  “No; that would look like we’re not doing anything,” responded another advisor.

  The officials settled on four.

  Equally strange was what the researchers of the 1976 JACEP airflow study concluded. Despite finding that back slaps had been “so ineffective in creating air flow or increased pressure within the chest,” the study, whose author was anesthesiologist and Red Cross advisor Charles Wayne Guildner, still recommended that a rescuer first apply four “back blows” and, if ineffective, repeat the “abdominal or chest thrust . . . until effective or until victim becomes unconscious.”14

  Figure 14.1. Battling against back blows: I fought for years to try to get the American Red Cross to stop teaching people to hit a choking victim on the back.

  RED CROSS TEACHINGS ARE EXPOSED

  It is mindboggling that an organization set up to help the public good would insist on teaching a first-aid method with so little proof of its effectiveness. Organization officials have certainly been aware of the fact that saving a choking victim is a race against the clock. Death occurs four minutes after the onset of choking. A lack of oxygen for less than that time can cause brain damage. I believe that delaying the use of the maneuver by hitting people on the back hastens the possibility of death, paralysis, or a comatose state.

  I have thoroughly researched the back-slap issue, and there is a plethora of evidence proving (1) back slaps cannot expel an object from a choking person’s throat and (2) back slaps can lodge an object tighter in the throat of a choking person who initially is breathing, causing his or her airway to become completely blocked.

  As an example, B. Raymond Fink, a University of Washington professor of research anesthesiology, proved at the 1976 National Academy of Sciences conference that, when a choking person is hit on the back, the obstructing object goes down deeper and tighter into the airway rather than loosening. Physiologically, the mechanics of this is intuitive and easy to visualize: back slaps cause the body, including the airway (larynx), to move forward. But the object, say, a piece of meat, does not move. Therefore, it ends up deeper in the airway, blocking breathing and causing death.15

  The potential harm of the Red Cross recommending back slaps was exposed further in a syndicated article from the Washington Post that appeared on April 22, 1979. The story was written by Jean Carper, who, herself, had choked on food in a restaurant in Washington, DC. Ms. Carper described the incident, explaining that when patrons first saw what was happening, some hit her on the back, which failed to dislodge the food stuck in her windpipe. Then a waiter saved her life by applying the Heimlich Maneuver.

  Ms. Carper’s article, titled “Beware the Back Slap If You’re Choking to Death,” bluntly criticized the Red Cross for continuing to teach people to hit choking victims on the back. “The Red Cross has not adopted and does not teach the Heimlich technique, even though the maneuver has now saved thousands of people. . . . Instead, the Red Cross teaches a bastardized v
ersion of the maneuver which Dr. Heimlich charges is injuring and killing people instead of saving them.”16

  Ms. Carper explained that the Red Cross had failed to answer the elephant-in-the-room question: Why continue to teach back slaps?

  “I have asked the Red Cross several times for evidence on the effectiveness of its method. Its response goes like this: The Red Cross is not a ‘medical’ organization; therefore, it relies on ‘medical advice’ from the National Academy of Sciences. An Academy committee in 1976 recommended the procedures the Red Cross teaches, including backslapping. The Red Cross has no obligation to dispute, confirm or investigate the validity of the recommendations.” Carper noted that the head of the Red Cross’s national first-aid program referred her to a report written by the National Academy of Sciences, but she found no evidence in the report that supported back slapping. Instead, she found twenty-five references, seventeen of which were unrelated to back slaps, while seven others provided evidence against back slaps. The one study that seemed to support back slaps was the one involving anesthetized baboons that Archer Gordon had discussed at the 1976 Red Cross meeting.

  In 1982, a new and enlightening study, conducted by the Yale University School of Medicine and the John B. Pierce Foundation, was published in Pediatrics and seemed to put to rest the question of whether back slaps work or are harmful. In “Choking: The Heimlich Abdominal Thrust vs. Back Blows: An Approach to Measurement of Inertial and Aerodynamic Forces,” researchers found that previous studies had failed to quantify the intense air pressure generated by the Heimlich Maneuver versus other thrusts, including back blows.