“Our data . . . show that the Heimlich maneuver is a powerful one,” wrote the researchers. Furthermore, they proved what I had been saying for so long: because of the way back blows “cause an upward acceleration of the neck and upper back of more than three times the force of gravity,” they wrote, it is “logical to imagine that in the case of partial obstruction, a back blow could transform the situation into one of complete blockage.”17
ABANDONING BACK SLAPS
In July 1985, Red Cross officials seemed to be coming around. The organization, along with the American Heart Association, made a joint recommendation that people use only abdominal thrusts to save a choking victim. According to the organizations’ press releases, they felt that both back blows and abdominal thrusts were effective but that the decision to drop back slaps was to simplify the teaching of first aid. Spokespeople for both groups stated that the adoption of the Heimlich Maneuver was still under review and that it was not expected to be officially adopted until the following year.18
During this time, I was urging US surgeon general C. Everett Koop to make a statement on the maneuver. Five years before, he had saved his young grandson from choking on a large chunk of meat. After applying the Heimlich Maneuver, Koop told reporters that the meat “shot about four feet across the room.”19
A few months after the Red Cross and the American Heart Association announced that they were considering abandoning back slaps, Dr. Koop made a bold statement: “Millions of Americans have been taught to treat persons whose airways are obstructed by a foreign body by administering back blows, chest thrusts, and abdominal thrusts. Now they must be advised that these methods are hazardous, even lethal,” Dr. Koop wrote. “The Heimlich Maneuver is safe, effective, and easily mastered by the average person.” Furthermore, he wrote, “I urge the American Red Cross, the American Heart Association, and all those who teach first aid to teach only the Heimlich Maneuver. Manuals, posters, and other materials that recommend treating choking victims with slaps and chest thrusts should be withdrawn from circulation,” wrote Dr. Koop.20
In 1986, the Red Cross and the American Heart Association formally released their standards and guidelines that endorsed abdominal thrusts as the only recommended response for choking adults and children victims.
At that point, I thought we were out of the woods. I was convinced that back slaps were a thing of the past.
I was wrong.
THE RETURN OF BACK SLAPS
In April 2006, twenty years after the Red Cross abandoned back slaps in favor of “abdominal thrusts,” the organization brought back slaps back as a first response to choking. The move was done quietly. So quietly, in fact, I had no idea it had happened. But, indeed, the organization began teaching that rescuers aid a choking victim by administering a series of five “back blows” and then five abdominal thrusts.21 The organization reaffirmed this position in 2010. (The American Heart Association continues to teach the Heimlich Maneuver—exclusively—for aiding choking victims.)22
Today, the Red Cross teaches rescuers to take this series of steps: First “send someone to call 9-1-1.” Then “lean person forward and give 5 back blows with heel of your hand.” After that, the Red Cross says one should “give 5 quick abdominal thrusts,” and then “repeat until the object the person is choking on is forced out and [the] person breathes or coughs on his or her own.”23
You don’t have to peruse an empirical study to understand the danger of teaching people to use back blows to save someone who is choking. Simply consider the perspective of the victim: the frightening experience of having one’s air supply cut off, the agony of being hit on the back to no avail, and, finally, the relief of regaining the ability to breathe after having been saved by a one, two, or three quick, upward thrusts to the diaphragm.
Joan Nathan, a renowned writer of Jewish cookbooks, described in a 2009 New York Times op-ed what this experience was like when she choked while at her home in Washington, DC. At the time, she was giving a dinner party for celebrity chefs.
“You would think that a house full of chefs would be the safest place if you were choking,” wrote Ms. Nathan. “But, unfortunately, more people have heard of the Heimlich maneuver than actually know to administer it.”
Ms. Nathan explained how she tried to swallow a large chunk of chicken. “For perhaps a minute, I stood there, praying that it would slide down my esophagus. Suddenly, it was stuck. I bent over to try to breathe.” Two men saw her distress and slapped her on the back. It did nothing. Then another man stood behind her and asked if she could talk. Ms. Nathan shook her head.
“The next thing I knew he was placing his fists below my diaphragm and applying sudden, sharp pressure just below my rib cage to force the air out of my lungs in the Heimlich maneuver.” After two tries, “the chicken popped out of my windpipe, leaving me with nothing but a slightly sore throat.” (Her “knight in shining armor” was Tom Colicchio, a judge on the television show Top Chef.)24
It is common, when I introduce myself to people, for them to tell me that they have saved someone using the maneuver or that they, themselves, were saved. Studies continue to support the use of the maneuver.25 Conversely, despite my repeated requests to the organization, the American Red Cross has never provided to me empirical evidence proving that back slaps can save the life of a choking person.
I have a Google alert set to “Heimlich Maneuver,” so that I read about someone choking and being saved with the maneuver on a daily basis, often more frequently. Sometimes, those news reports describe a choking victim being hit on the back. When nothing happens, the individual is then saved with the maneuver. Other times, when the maneuver is not applied, the individual dies or suffers brain damage or both.
For example, on July 24, 2013, a news story emerged from Farnworth, England, about a woman who was having dinner with her boyfriend, Neil Whitcher, at a restaurant when she began to choke. Fifty-six-year-old Helen Marie Peploe did what many restaurant patrons do when they choke: they leave to avoid embarrassment. Ms. Peploe went into the restaurant’s restroom; Mr. Whitcher quickly followed her. Later, he told the media that “she was suffocating,” but he “couldn’t get round her properly” to perform the Heimlich Maneuver, so he began “banging her on the back.”
Mr. Whitcher said he was “terrified and panicking and shouting for her to keep fighting,” but it was no use. Ms. Peploe collapsed and was then taken to the hospital, where she remained in a coma and then died. What is particularly shocking is how the article covering the story ends with instructions for how to save the life of a choking person. The newspaper’s advice? “Give up to five sharp blows between the person’s shoulder blades with the heel of your hand,” and, if the blockage has not cleared, “give up to five abdominal thrusts.”26
I believe nothing I could say could drive home the dangers of back slaps better than an e-mail I received from Innes Mitchell, a professor at St. Edwards University in Austin, Texas, on May 9, 2013. In 2010, Dr. Mitchell had brain surgery that resulted in his left vocal cord being paralyzed. Consequently, he has difficulty swallowing and is prone to choking when he eats. A few months after his operation, Dr. Mitchell and his sister were enjoying Sunday breakfast at a restaurant when he began to choke on his food. His sister began to thump him on the back.
“I could feel the force of her blows vibrate through my chest, but her efforts lodged the obstruction more firmly and tightly in my airway,” Dr. Mitchell wrote. “I was in no position to tell her to stop, but I remember taking a few steps away. . . . I began experiencing the onset of oxygen deprivation, namely vision blurring and physical weakness.” Another restaurant patron then rushed up and performed the Heimlich Maneuver on Dr. Mitchell. After four or five thrusts, the food dislodged and he was able to breathe again.
“It was an exhausting experience and I took several minutes to recover,” he wrote, “but I have no doubt the man who performed the Heimlich Maneuver saved my life that Sunday morning.” Dr. Mitchell thoughtfully suggested tha
t when people hit a choking victim on the back, they could trigger a “bystander effect” in which potential rescuers hesitate to intervene because they assume that the choking victim is being helped. “This delay in performing the Heimlich Maneuver can waste critical seconds and turn an already critical situation into a deadly one,” he wrote.
Dr. Mitchell has choked on food twice since that episode. Each time, his wife has performed the Heimlich Maneuver to save him. When he goes to a restaurant today, he looks for a poster depicting instructions for how to save a choking victim and is relieved when those instructions say to perform the Heimlich Maneuver.
I have no desire to diminish the good work that the American Red Cross has done, but by recommending back slaps, the Red Cross is putting people’s lives at risk unnecessarily. I again call on the American Red Cross to stop promoting back slaps as a method to save the life of a choking victim and to adopt exclusively the Heimlich Maneuver as the preferred method. If the organization were to do that, I would gladly allow it to use the name Heimlich Maneuver in its teaching materials.
As Innes Mitchell wrote in his e-mail, “Choking is a dreadful and frightening experience. I believe the back slapping protocol advocated by the Red Cross is dangerous and could possibly jeopardize the safety of choking victims. Back slapping complicates an already traumatic situation and should not be disseminated as public knowledge by a reputable health organization.”
Jean Carper stated as much in her article. “A reputable organization like the Red Cross that enjoys the public trust should not hide behind bureaucratic buck-passing when lives are at stake.” Carper added, “In the meantime, if I’m ever choking again, I’d prefer my rescuer to forego the back slaps. Just the Heimlich maneuver, please.”27
We often take for granted our ability to breathe. But for many people, like patients afflicted with such lung-related illnesses as emphysema, cystic fibrosis, severe asthma, pulmonary hypertension, and chronic obstructive pulmonary disease (COPD), breathing is a real struggle. Children with cystic fibrosis are also impacted.
I remember one day, during the 1980s, when I was visiting with patients at Deaconess Hospital. (By that time, I was a member of the surgical staff there.) I observed several patients receiving oxygen and noticed that they were tethered to oxygen tanks by a thin tube that delivered oxygen through a cannula, a small, plastic, two-pronged device that sits in the nose. To keep the cannula in place, the tubing ran on either side of the patient’s face and over the ears. The patients looked exhausted as they strained to take in each breath.
Soon I would learn why patients taking oxygen strain to breathe, and I would come up with a simple device that would relieve the strain.
Many Americans need to receive oxygen to live, as the number of patients who suffer from lung disease is staggering. Chronic obstructive pulmonary disease is the fourth leading cause of death in the United States, accounting for more than 120,000 deaths per year and costing more than $30 billion per year. It has been estimated that more than 24 million Americans have COPD.1 Back in 2005, the National Lung Health Education Program estimated that approximately 1.2 million Americans were on long-term oxygen therapy.2
To breathe normally—or to try to breathe normally—these patients need special equipment. Fortunately, this equipment has improved in the last thirty years. Rather than be dependent on oxygen tanks, most patients use what is called an oxygen concentrator. A concentrator is the size of a small suitcase and provides oxygen therapy to patients at higher concentrations than are found in available ambient air. Unlike the old tanks that had to be filled with oxygen, concentrators plug in to an electrical socket and quietly generate oxygen from the air. Patients are usually connected to the concentrator by fifty feet of tubing. If they need to be any farther from the machine, which can weigh up to sixty pounds, they wheel it to the new location. To be even more mobile—say, if they want to leave their home—patients carry a small, five-pound tank of oxygen. The portable tank allows a patient about two hours of oxygen. To conserve the flow of oxygen so that patients get more breathing time, they can engage a “pulse flow” mechanism that emits a burst of oxygen only when the patient inhales rather than sending out a steady stream of oxygen.
But what hasn’t changed since I took a look at those patients in the hospital many years ago is the way they breathe in the oxygen. Most still take in oxygen through the two-pronged, nasal cannula, which is still held in place by looping the oxygen tube from the cannula around the ears.
So what caused those patients I observed to be so exhausted carrying out the simple act of breathing? The problem lay in the delivery system—that is, taking oxygen through the nose.
THE STRUGGLE TO BREATHE
Why is taking oxygen through the nose so exhausting? Because it’s wasteful. In fact, as much as 50 percent of generated oxygen does not end up reaching the lungs. The rest escapes from the nose and mouth. These escape routes make up something called “dead space.” Patients are exhausted because they are trying to make up for the wasted oxygen—oxygen that should be entering the lungs but, instead, escapes.
There are other problems associated with taking oxygen nasally. The cannula can come out of the nostrils at night, interrupting oxygen flow. Also, it makes taking oxygen terribly conspicuous. Many patients would prefer others not be aware that they are taking oxygen, but the visible, pronged tubing in the nose, along with tubing encircling the head, makes hiding this act impossible. One woman told me how she felt humiliated when her grandchildren visited her and asked, “Grandma, what’s that in your nose? Are you dressed for Halloween?” Thereafter, whenever they were around, she chose to gasp for air rather than wear the embarrassing nose prongs. The “pulse flow” mechanism to conserve oxygen makes the problem of conspicuousness even worse. Each time the device pulses, it emits a clapping-like sound, which just about anyone nearby can hear.
Back in the 1980s, when I began studying the problems posed by the nasal cannula oxygen delivery system, I began to ask: Is there a more efficient way for patients to take in oxygen so that a lot more of it reaches the lungs? Was there a way to bypass the dead space or just avoid it altogether? If we could accomplish that, the patient could get more use out of a light, portable oxygen container. Today, I reason that such an improved system would reduce the need for the noisy, pulsing airflow-delivery mechanism as well as the large, cumbersome concentrators. And patients would not have to struggle so much to breathe.
A simple solution stared me in the face: Do away with the nasal cannula and, instead, deliver oxygen directly into the trachea.
A TINY, SIMPLE DEVICE
To allow patients to take in oxygen through the trachea, I needed to create a device that was lightweight, because the patient would have to wear it comfortably around the neck. The device needed to be small so it did not show easily. And it would have to be secure so that the oxygen flow would not be interrupted, even at night. After some study, I came up with a gadget that I believed would do the trick—something that I would call the Heimlich MicroTrach.
The MicroTrach consists of a three-and-a-half-inch-long, tiny, plastic tube, as narrow as a tube that is inserted into a vein for giving intravenous fluids. The tube is attached to a flat piece of butterfly-type wings made of soft plastic. The plastic wings rest against the neck, and a thin metal chain holds the device in place, strung through holes in the plastic wings. In 1991, I had the Heimlich MicroTrach patented.
The procedure for inserting the MicroTrach is simple. It’s comfortable to use, and it can change people’s lives forever.
Figures 15.1. and 15.2. A tiny device: The Heimlich MicroTrach delivers oxygen through the trachea and into the lungs, eliminating the need for a nasal cannula. (Figure 15.2 [right] courtesy of Terri Lusane.)
The greatest advantage of the MicroTrach is that it allows patients to take in oxygen in a highly efficient manner. Unlike what occurs with conventional nasal tubes, patients breathe in nearly every liter of oxygen delivered, allowing them to
make more use of a portable tank. What’s more, because the oxygen enters the trachea below the dead space, the patient breathes quite normally.
Receiving oxygen through the trachea is safe. Animal studies done in 1974 proved that plastic transtracheal catheters were tolerated for more than a year with no irritation, mucosal lesions, or formation of mucus balls.3 Another benefit of the MicroTrach is that insertion—performed by a medical professional—takes only about fifteen minutes. First, the patient lies down on his back with his head and shoulders resting on a small pillow; his head is bent slightly back, so that his neck is extended a bit. After injecting a local analgesic into the skin of the neck over the trachea, the doctor makes a tiny incision less than a quarter of an inch long. A long needle is pushed through the incision and into the trachea. Then a guide wire is inserted through the needle, into the trachea, and left in place as the needle is then removed. Next, the physician slides the MicroTrach tubing, with its winged plastic piece, over the guide wire and into the trachea, and the wire is removed. A jewelry chain is attached to the device and worn around the neck to keep the MicroTrach secure. The doctor then starts the flow of oxygen to the MicroTrach, turns off the oxygen that had been delivered through the nasal cannula, and removes the cannula from the patient’s nose. The patient then returns once a month to have the device inspected, cleaned, and replaced as needed.
The idea of making an incision into the trachea might seem scary to some, but the hole in the front of the neck is hardly visible. In fact, it’s only about the size of a hole in a pierced ear. Having such a tiny hole is not only much more cosmetically pleasing than the nasal cannula, it also reduces the possibility of infection. If the MicroTrach should come out accidentally, a doctor can easily reinsert it. The patient should not attempt to reinsert it, because a doctor can make sure that it is done under sterile conditions. Some patients may be advised to have on hand a backup oxygen-delivery system, which they can use until a doctor reinserts the MicroTrach.
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