A New Maneuver

The circular history of a life-saving procedure.

By Pamela Mills Senn

Someone near you is choking. Or imagine it’s you struggling to breathe, that once-delicious, now-deadly chunk of porterhouse lodged in your windpipe. What would you want someone to do? If you said “Heimlich me,” you’re like most people. For decades, the Heimlich Maneuver, introduced in 1974 by Dr. Henry Heimlich, then chief of surgery at Jewish Hospital, has been as strongly associated with choking as Elizabeth Taylor has been with divorces and diamonds. However, if the American Red Cross (ARC) has its way, that’s about to change.

Last year, the ARC changed its first aid training regarding choking. Now, rather than using abdominal thrusts—i.e., the Heimlich Maneuver—on a conscious choking victim, they’re training people to respond first with five back blows, then five abdominal thrusts, if the object is not dislodged by the back blows. ARC press releases urge people to “remember ‘five-and-five’ for choking.”

Considering the fame of the Heimlich Maneuver, it seems like it’ll take more than a snappy catch phrase to catch on. Is there a person alive who hasn’t seen the maneuver demonstrated? What prompted the ARC to change a first aid procedure that’s easy, effective, and famous?

The reason for the change, according to the ARC, is simple: it has to do with research. But explore how the maneuver came to be choking’s gold standard in the first place, and it’s evident that nothing about the procedure has ever been simple. It raises a disquieting truth, the sort of thought you don’t want to have flash through your mind if you’re gagging on a piece of gristle: Does anybody really know what to do?

IF YOU TOOK a first aid course in the 1950s, you probably would have been taught to assist a conscious choking victim by soundly thumping him or her on the back. But in the early 1970s, Henry Heimlich found another way.

Heimlich conceived of what became known as his “maneuver”—a quick, sharp, upward thrust performed by standing behind a victim with your arms wrapped around his upper abdomen. Experimenting on anesthetized beagles (and, later, volunteer doctors), he determined that this maneuver was more effective than back blows. He also concluded that back blows would actually lodge an object more tightly or even drive it in deeper.

An associate of Heimlich at the time, Edward Patrick (today an ER physician in Union, Kentucky), constructed an “energy model” to describe how energy expelled a foreign body airway obstruction. Back slaps resulted in more pressure than energy, Patrick posited, and it was energy, more than pressure, that removed an obstruction.

Heimlich published their results in 1974, but the medical community remained unconvinced. So Patrick and Heimlich took the maneuver directly to the public, demonstrating it on television talk shows and asking folks who had either used the maneuver or had it performed on them to get in touch and share their stories. Thousands did. Heimlich also very publicly took on the ARC and American Heart Association (AHA) for their refusal to embrace his technique. In medical journals and consumer magazines, he called back blows “death blows,” and accused both organizations of foisting a deadly method on the public.

Less public was the way Heimlich’s effort may have impacted decisions made by those two organizations. The backstage drama of how the Heimlich Maneuver replaced backslaps in the AHA’s choking guidelines, which the ARC mirrored in their own training, is available now, thanks primarily to Heimlich’s estranged son, Peter, who has spent the past five years collecting material that he believes discredits his father’s work. (Cincinnati Magazine reported on the father-son feud in December 2005.)

According to a June 1980 AHA memo, Heimlich’s opinions were presented and discussed at the AHA-sponsored National Conference on Standards for Cardiopulmonary Resuscitation and Emergency Cardiac Care, held in Dallas. This conference included a session on choking attended by more than 100 experts on the topic. The memo’s writers—Howard L. Lewis and Christopher Land, who served in the communications division of the AHA science information section—stated that the attendees, by consensus, decided that it was not possible to “designate any single technique as the only recommended method in all instances of choking.” It was decided that the new standards would “reiterate that a combination of back blows and abdominal thrusts (the Heimlich Maneuver) is more effective than either technique used alone. Evidence presented at the conference clearly showed that back blows can save lives.”

Because the evidence indicated that no single method is always successful, the memo said, training programs should use a combination of methods. It was decided that the sequence for a conscious choking victim would be “four quick back blows” followed by “four upward abdominal thrusts or four backward chest thrusts” if the object wasn’t dislodged.

This memo was intended to update science and medical writers and the media, as well as counter another one of Heimlich’s very public campaigns: pushing to get his maneuver inserted into the guidelines for cardiopulmonary resuscitation. “CPR is used by trained laymen to attempt to save heart attack victims in the first few minutes following their attack,” Lewis and Land explained in their memo. “CPR has a much greater potential for saving lives than the Heimlich Maneuver because more than 350,000 people die each year of sudden heart attacks compared to the estimated 3,000 people who choke to death.”

The brouhaha surrounding the maneuver was becoming detrimental, the memo warned. “If this confusion continues and it affects the willingness of laypersons to take CPR training, lives that might have been saved will be lost.”

EVERY FIVE YEARS, international teams of experts in cardiopulmonary resuscitation gather to review new scientific evidence to see if any of the guidelines need to change. When the 1985 conference on guidelines for CPR and emergency cardiac care rolled around, Heimlich was there again, urging that his maneuver be adopted across the board: for a conscious choking victim; for an unconscious victim in the CPR sequence (where an airway obstruction is suspected); and as a first response for drowning.

According to Mary Fran Hazinski, the AHA’s senior science editor for emergency cardiovascular care and a clinical nurse specialist in pediatric emergency and critical care at Nashville’s Vanderbilt Children’s Hospital, little new choking research or data was presented at that conference. What there was came from Heimlich, in the form of anecdotal case studies from small groups of patients. “These [case studies] are rated at a very low level of evidence,” explains Hazinski, who didn’t attend the 1985 conference but is familiar with its history. “Today they would not be given much credibility at all. But at the time, they were the only level of evidence available on choking.”

James Atkins, a Dallas physician who sat on the emergency cardiac care committee and was present at the consensus conference that year, explains that all the data they had on choking—back blows or otherwise—was anecdotal; it was, and still largely is, the nature of the beast. “You can do anecdotal studies, and animal studies, and anesthetize patients and measure certain things, but this is different from human data where people actually experience obstructions,” says Atkins. “Obstructions are all different, and the anatomy is different, the agitation level is different. And frankly, Heimlich had more anecdotal data.”

Ultimately, the 1985 conference adopted the Heimlich Maneuver for choking and also inserted it into the CPR sequence in situations where an airway blockage was suspected. Charles Guildner, an anesthesiologist and consultant to the AHA’s emergency cardiac care committee from 1973 to 1980, thinks he knows why.

Guildner, now retired and living in Everett, Washington, had read Heimlich’s 1974 study and thought it was a great idea. “It made sense to me,” he recalls. He decided to repeat the study on human volunteers, and expanded it to include comparisons between back blows, the abdominal thrust, and also a chest thrust, which no one had yet applied to the conscious choking victim. Guildner discovered that, compared to back blows and the maneuver, the chest thrust produced higher peak pressure and greater volume, meaning that chest thrusts could be more efficient at dislodging an obstruction.

When he reported his findings to Heimlich, Guildner says, the doctor became angry and said the work had no value. Accusing him of unethical practices because of his use of human volunteers, Heimlich filed complaints against Guildner with a variety of associations, including the AHA, the American Medical Association, and the American Society of Anesthesiologists, as well as at the hospitals where he practiced.

Guildner was eventually absolved of all charges, but the investigation had a chilling effect. “I think what happened to me caused others to stop and think before going up against Heimlich,” he says.

SO WAS BADGERING, not science, the reason for the switch from back blows to the maneuver? Dr. William Montgomery, who chaired the 1985 CPR conference and currently practices in Hawaii, and Dr. Roger White, who chaired panel discussions on the management of foreign-body airway obstructions and who currently serves as consultant and professor at the Mayo Clinic, told me via e-mail that neither Heimlich’s antics nor concerns over the AHA’s and ARC’s reputations had anything to do with the decision—although they both recall that there was no especially compelling evidence or argument in favor of the maneuver.

However, in a 2004 e-mail to Peter Heimlich (who corresponded with White using a pseudonym), White is significantly less blase about Dr. Heimlich’s role. “There was never any science here,” White wrote. “Heimlich overpowered science all along the way with his slick tactics and intimidation, and everyone, including us at the AHA, caved in.”

When I asked him to explain this apparent discrepancy in his point of view on the medical establishment’s adoption of the Heimlich Maneuver, White continued to insist that Heimlich exerted no influence whatsoever over the committee. “The only ‘intimidation’ would perhaps have come from some media pressure that always surrounded Dr. Heimlich,” he stated in an e-mail. He added: “In the end, our recommendations did not please Heimlich”—the group at the 1985 conference deemed the maneuver too dangerous for infants, and also declined to adopt it for drowning victims—“so I would hardly call that caving in.”

As for Heimlich’s reputed browbeating, James Atkins, who was present for those discussions, says that the scientific community was not as genteel then as it is now. “It wasn’t considered unusual to say, ‘You idiot!’” he recalls. In those more contentious times, he says, Heimlich’s behavior “would not have had much of an influence.” According to Atkins, the maneuver had become a big issue and the public was doing it anyway, so the decision was made to accept it, make it teachable, and put the attention back on cardiac arrest guidelines. “We thought, let’s just take the Heimlich evidence; we have nothing to support back blows,” he says.

Still, Guildner sees things differently. “I think Heimlich had a great deal to do with the AHA accepting the maneuver,” he says. “His diatribes wore people down. They just wanted him to be quiet and go away, and one way to do this was to give him what he wanted.”

In the summer of 1985, then–U.S. Surgeon General C. Everett Koop received a letter from Edward Patrick in which Patrick alerted Koop to the changed guidelines and put forward Heimlich’s contention that backslaps were dangerous and ineffective. (There also were, and still are, concerns about the potential for serious injury from using the maneuver. Case studies have chronicled maneuver-related damage such as ruptured spleens, livers, intestines, and aortas.)

Koop got on the Heimlich bandwagon. In The Washington Post, he called the maneuver “the only method” that should be used for choking (though for children under one year Koop still advised back blows) and urged that other methods be immediately discarded. An outspoken advocate, Koop described the Heimlich Maneuver as “the best rescue technique in any choking situation.”

With the endorsement of the Surgeon General, the status of the Heimlich Maneuver for choking rescue was assured.

NOW, FAST FORWARD two decades: the American Red Cross has—rather suddenly, it seems—changed its training again.

In a nutshell, here’s the “five-and-five” choking response developed by the ARC: If the person is conscious and choking, lean him forward and give five sharp back blows between the shoulder blades followed by five quick abdominal thrusts if the object isn’t dislodged. It’s virtually the same procedure outlined in the AHA’s 1980 memo.

The change came on the heels of the 2005 international conference on CPR. Once again, experts from around the world reviewed the resuscitation and choking evidence. Most of the research they looked at came from the 1970s, ’80s, and ’90s (which presumably would have been considered by previous conferences), but added to the mix was a 2004 study about pediatric airway obstruction from the journal Prehospital Emergency Care and a 2000 study from Annals of Emergency Medicine that examined telephone-assisted Heimlich Maneuvers. It seems like scant new information was available. But apparently new and old data together were somehow compelling enough to the ARC to put backslaps back in the picture.

Dr. David Markenson, who chairs the ARC advisory council on first aid and helped develop the new guidelines, explains that they decided to follow the document produced from the conference (entitled Consensus on Science and Treatment Recommendations, or CoSTR) “to the letter.” CoSTR acknowledges that it’s unclear if back blows, abdominal thrusts, or chest thrusts should be used first, but states that all three methods can be effective: “These techniques should be applied in rapid sequence until the obstruction is relieved: More than one technique may be needed.”

So why have they decided to train people to try back blows first? That’s not the most important part of the change, Markenson says in his e-mail response to my question. “The issue is the number of methods that should be used to help relieve a [choking victim],” he writes. “The research is clear that more than one method should be used. We must teach what the latest scientific review shows is best. To do any less would be to deprive the public of the best chance for survival.”

It’s a change that suggests that assisting a choking victim is a sort of frantic, try-anything proposition. That’s unsettling, but not necessarily inaccurate. As James Atkins has pointed out, each choking emergency is different. No one can say with certainty what method works best the majority of the time. The five-and-five sequence “is probably the most logical move at this time,” Atkins states. “From the limited data that is present, it sounds like the most reasonable approach.”

Now that the decision has been made, the task remains to get the word out. The change was made a year ago and, so far, it doesn’t seem like many people are aware of it. But ARC spokesperson Pam King says that the organization is going through a sequential process: ARC instructors had to be updated and trained first. That’s been done, so now it’s the public’s turn. The new choking posters are hot off the presses, and local ARC personnel are starting community outreach, she says.

And what does Heimlich, who spent so much of his career defending his maneuver against all comers, think of this change? Heimlich, now 87 and still living in Cincinnati, did not respond directly to questions for this article, opting to communicate instead through his publicist.

“I am gratified every day when I reflect on the thousands of lives that have been saved since the Heimlich Maneuver was first reported in 1974,” he says. “I think that record clearly demonstrates its effectiveness.”

Originally published in the April 2007 issue.