Heimlich controversy

A crewmember falling overboard is the most extreme example of a water emergency that a mariner may have to face. In addition to the difficulty of getting the crewmember back on board, there is also the issue of reviving a potential drowning victim. If conditions are rough or if the crewmember fell in without flotation, the victim may have swallowed considerable amounts of water by the time he or she is back on deck.

There is new thinking on how to clear water from a victim’s lungs. Henry Heimlich, M.D., the man who invented the Heimlich maneuver for aiding choking victims, is now saying that his eponymous maneuver is a better way to revive drowning victims than the technique of cardiopulmonary resuscitation favored by the Red Cross.

Twenty-five years ago Heimlich took on the medical establishment over the proper way to aid a choking person. Heimlich maintained then that abdominal thrusts (later named the Heimlich Maneuver) were much better at clearing blocked airways than back-slaps. After a period of spirited resistance, an alliance of the American Red Cross, the American Medical Association (AMA), and other agencies reluctantly yielded and the Heimlich Maneuver became accepted first aid for choking.

Heimlich says the Red Cross is wrong again. This time it’s about drowning rescue. The Red Cross, which trains more lifeguards than anyone else in the country, instructs its students to use cardiopulmonary resuscitation (CPR) as the primary means of resuscitating non-breathing drowning victims. Heimlich says this is the wrong approach. He claims the Heimlich Maneuver should be the first action taken to revive non-breathing victimsthat use of the maneuver clears the airway of water. The use of CPR is appropriate only when the victim fails to revive following administration of the maneuver.

The Red Cross has closed ranks again with the AMA, the National Research Council, and the American Heart Association (AHA), all of whom are unwilling at this point to change standard drowning rescue protocol. The Red Cross takes its cues from the Emergency Cardiac Care (ECC) Committee of the American Heart Association. In the summer 1994 issue of its official newsletter, Currents, the ECC stated five reasons why the Heimlich-first theory doesn’t hold water:

“One, lack of scientific evidence that water blocks the airway. Studies show that rescuers can successfully push air and oxygen into the lungs of a near-drowning victim with CPR ventilation. CPR pushes any water out of the airway and into the lungs, where it is absorbed in the bloodstream.

“Two, the belief that aspiration of water kills drowning victims is not supported by scientific evidence. Studies of drowning victims show that it is the lack of oxygen that causes damage to the heart and brain that leads to death.

“Three, the belief that water must be removed is not supported by scientific evidence. When water enters the lungs it damages them; removing water would not lessen the injury.

“Four, the belief that abdominal thrusts remove large volumes of water from the lungs is not supported by scientific evidence. Studies show that most drowning victims do not aspire (inhale) large volumes of water. Furthermore, most drowning victims swallow considerable amounts of water. Heimlich’s reports do not specify whether the fluid expelled was water or stomach contents.

“Five, Heimlich bases his beliefs on only a handful of cases. Over the course of the 15 years of controversy no other research supports the use of the Heimlich Maneuver for near-drowning. While the use of CPR withstands scientific evaluation, the use of the Heimlich-first fails to meet such scrutiny.”

The Heimlich, if used at all, should be used only if CPR fails. The AHA admits the maneuver is effective in dislodging food from throats, but they say that evidence it can force liquid from the lungs is insufficient.

Early in 1996 the American Heart Association reiterated its position, issuing the following statement recommending the use of CPR first to “open the airway and force air into the lungs.” The AHA then moderated its position somewhat, advising that rescuers are to “use the Heimlich Maneuver if CPR cannot proceed due to an airway blocked by foreign matter.”

Heimlich’s response to all this, however, is that 90% of all drowning victims inhale water, so it’s fairly safe to assume there’s water somewhere blocking the airway. So why wait? Do the Heimlich first. Study supports Heimlich

A recent university study agrees with Heimlich. The Heimlich was embraced in the spring of 1996 by the University of Houston, whose research concluded that two to four Heimlich Maneuvers clear the lungs of waterthe most important step in resuscitationwhile other techniques may either force water deeper into the lungs or do not allow the water to be expunged quickly enough.

CPR, in fact, may even be counterproductive. “Blowing water into the lungs cannot possibly be of benefit to the victim,” said University of Houston professor of industrial engineering John Hunsucker, director of the study and, ironically, a career Red Cross aquatic volunteer who has trained thousands of lifeguards. “Whereas the Heimlich may expel some portion of the water and thus enable the ventilation to be more effective.”

A Los Angeles County lifeguards’ organization tends to agree with the Houston study. “CPR is not effective unless you’ve got an open airway,” said Lt. Mike Henderson of Hermosa Beach, Calif. “The first step is to clear the airway, and if that involves the Heimlich maneuver to remove an obstruction then that’s what we do. The obstruction may just be water in the lungs. Our protocol is to begin with the Heimlich if we don’t have a clear airway.” These are not idle questions. Every hour or so someone in this country

drowns. Figures from the National Institute of Health say 7,700 Americans die each year from drowning. In adolescents, drowning is the second leading cause of accidental death, and it is the seventh leading cause of accidental death for adults. Four people die every day in boat-related drownings.

Critics of the Heimlich say valuable time is wasted on a procedure that does not provide oxygen to a victim who isn’t breathing. The study indeed showed the first breath is delayed four to six seconds while as many as five Heimlich Maneuvers are performed on the victim. Its ability to eject water from the airway before initiating CPR, however, was found to be invaluable.

In fact, the study found many times that the Heimlich was so successful that CPR was not even necessary. Of 27 drowning incidents reported in 1995 by lifeguards trained by the National Pool and Waterpark Association, 24 non-breathers were revived after employing the Heimlich alone, and only three required CPR after the Heimlich was administered. All 27 lived. Incidentally, the average hospital stay of victims who are revived with the Heimlich is one day, while the average stay of those rescued with CPR is three days.

Danger of regurgitation is another concern Heimlich critics cite. According to Heimlich, however, “vomiting occurs in 86 percent of drowning victims after CPR because rescue breathing distends the water-filled stomach. Fewer than three percent of drowning (or choking) victims vomit after the Heimlich Maneuver.”

Unlike CPR, the Heimlich isn’t dangerous to the victim. Although it’s a moot point for someone who isn’t breathing, CPR routinely results in damage to the victim. “If you do closed-chest compressions and CPR,” said Hunsucker, “the probability is almost 100 percent that you’ll break a rib or separate the sternum, whereas there are fewer than 20 documented cases of the Heimlich injuring anyone.” One enormous advantage the Heimlich has over CPR is of particular interest to ocean sailors, who spend much of their time around water: the Heimlich can be performed in the water, even deep water. Waterpark lifeguards no longer wait to pull a victim on deck before beginning resuscitation; they do the Heimlich right in the water. “We teach these kids to do this in the water. You Heimlich them right where you find them,” said Hunsucker, who estimates he has trained more than 10,000 lifeguards to use the “old” method in his 20,000 hours of Red Cross volunteer work prior to becoming involved in the study. “To gain enough mobility to perform the maneuver while treading deep water, wedge a flotation device between you and the victim’s back, then begin the thrusts.” Little training required

Another advantage of the Heimlich, says the study: the Heimlich can be done by anyone. “There is not always a lifeguard around during a drowning,” says Heimlich, “but there are over 250 million Americans not trained in CPR who know how to perform the Heimlich Maneuver or can learn it in one minute.”

The Heimlichinvolves four-steps:

1. Wrap your arms around the victim’s waist from behind.

2. Make a fist and place the thumb-side against the victim’s abdomen, below the ribs and above the navel.

3. Grasp your fist with the other hand and press inward and upward with a quick thrust.

4. Repeat until water no longer flows from the mouth.

The Heimlich lifts the diaphragm and forces an artificial cough. In the case of choking, the cough is caused by air forced from the lungs, which expels the obstructing object. In the case of drowning, water itself is forced from the lungs.

One additional feature favorable to Heimlich-first is that exposure to infectious diseases is avoided. “That’s another very important aspect that none of the agencies have looked at, and that is by using the Heimlich neither rescuers nor victims are exposed to infectious diseases, like HIV, hepatitis, and tuberculosis, that can be transmitted in body fluids. If even only 10% of the population is infectious, that’s one in 10 that if you ventilate them you’ve got a chance of getting what they have, or giving them what you have,” said Hunsucker.

The Houston study was commissioned by Jeff Ellis and Associates, an organization of international aquatic safety consultants, which announced in 1995 that all of its lifeguard instructors would be trained to use the Heimlich maneuver, not CPR, as the initial treatment for non-breathing drowning victims. Ellis is the second largest trainer of lifeguards in the world. In 1995, National Pool and Waterpark personnel trained by Ellis’ organization performed lifeguarding services for 43 million people. ”

Nothing else is going to clear the water out of the airway,” said Hunsucker. “It may or may not clear water out of the lungs; they can argue about thatSomeone’s got to have enough guts to say, ‘Look, guys, the only bad thing [about Heimlich-first] is it takes four to six seconds. It delays that first breath that long.’ Everything else is a red herring.”

For further information contact The Heimlich Institute, Cincinnati, Ohio 513-221-0002; the American Red Cross, Falls Church, Va. 703-206-7799; or the American Heart Association, New York, N.Y. 800-AHA-USA1.

Douglas Page is a freelance science writer who lives in Redondo Beach, Calif.

By Ocean Navigator