Medical data shows the Heimlich maneuver is not effective in drowning rescue and may do more harm than good. Why is one agency still mandating use of the practice?
Author: Kendra Kozen / Aquatics International
Date: May 06, 2012
Chances are, you’ve heard of the Heimlich maneuver. Since Dr. Henry Heimlich first introduced it in 1974, the abdominal thrust technique known as the “Heimlich maneuver” has become part of the popular lexicon, synonymous with saving lives.
Today, it is widely recognized as part of appropriate protocol to save choking victims.
But aquatics professionals may have been hearing about the Heimlich in another context: drowning rescue. That’s largely thanks to Henry Heimlich himself and one paragon of aquatics, Dr. John Hunsucker, founder of the National Aquatic Safety Co.
Recently, Hunsucker published data claiming that his protocols, which include the Heimlich, have shown dramatic results in saving drowning victims.
However, medical reports supporting use of the Heimlich on drowning victims is highly suspect. For years, a cadre of experts has refuted Heimlich’s original claims that the technique should be used in drowning. Today, Dr. Heimlich’s own son is perhaps his biggest critic. Peter Heimlich, along with his wife, Karen, has been investigating Dr. Heimlich’s work since 2002. They have started a Website, medfraud.info, to bring to light what Peter calls his father’s “dangerous, thoroughly discredited medical claims.”
While some might question the motivation of a son out to discredit his father, the issue is clearly more than a family feud. What’s more, the years of controversy between Heimlich and the rest of the medical community — and Hunsucker’s refusal to back down from his all-but-discredited position — perhaps says as much about the slippery nature of studies and research as it does about the Heimlich itself.
Here’s what is known about the Heimlich as it relates to drowning prevention: It is not recommended by any medical authority as a rescue technique for drowning. Furthermore, evidence suggests that performing the Heimlich maneuver in an underwater submersion incident actually could be harmful.
“The Heimlich is not an accepted medical practice as response for drowning victims. Unless the medical authorities — the American Heart Association, Red Cross — were to adopt it, I don’t see how anyone could advocate its use,” says Gerald Dworkin, a consultant with Lifesaving Resources Inc. in Kennebunkport, Maine. “Dr. Henry Heimlich is the only one who has come up with supporting studies. We should not be doing anything that’s not approved by the medical authorities.”
Heimlich began touting the technique as a means to revive drowning victims almost as soon as it was introduced. In a 1975 article in the Journal of the American Medical Association, he wrote about Victor H. Esch, MD, of Potomac, Md., claiming that Dr. Esch watched a lifeguard rescue a nearly dead drowning victim at Rehoboth Beach, Del., and then — somewhat miraculously — Esch stepped in to help by applying abdominal thrusts. He claimed to have gotten the idea after reading a recent article about Heimlich’s new choking rescue method, which had been introduced only three months earlier.
According to Heimlich, Esch’s actions revived the victim. Over the next several years he published articles in several other journals, describing at least one other case study where the victim also reportedly was saved by the use of the Heimlich maneuver.
Heimlich asserts that when people are drowning, they aspirate large amounts of water into the lungs. He further affirms that to save the life of a drowning victim, rescuers must clear the water from the lungs and, simply put, the best way to do that is his abdominal thrust technique.
However, researchers — including Dr. Jerome Modell, a leading drowning expert now retired — have discredited Heimlich’s theory from the beginning.
Modell’s research, along with that of other experts, concludes that no scientific data supports the theory that drowning victims aspirate lots of water, which causes an obstruction in the airway. The findings appeared in publications such as the New England Journal of Medicine and the Journal of Emergency Medicine throughout the last several decades.
Heimlich’s successful lobbying
Still, Heimlich apparently had some success championing his position.
In 1985, a committee of the American Heart Association (which included some of the experts directly opposed to Heimlich’s theory) accepted the use of abdominal thrusts for drowning rescues in cases where there might be foreign objects obstructing the airways. The recommendation, which appeared in a JAMA article the following year, reads:
“Since the risk-benefit ratio of a subdiaphragmatic abdominal thrust in this setting is unknown, the only time it should definitely be used is when the rescuer suspects that foreign matter is obstructing the airway or if the victim does not respond appropriately to mouth-to-mouth ventilation.”
Modell affirms the decision to include the abdominal thrusts was specifically for cases where a drowning victim may have a solid object blocking the airway. Some might see it as a direct concession to Heimlich.
According to some investigative reports, correspondence from that time indicates that Heimlich operated by threatening other experts, and accusing them of fraud. He launched a media campaign to discredit the American Heart Association and other rescue agencies, claiming that they made errors when CPR was adopted as a first response in 1960.
But information uncovered by Peter Heimlich indicates that actually it was the case studies his father used to support his position that were at issue, and it appears fraudulent, in many instances.
“For 30 years, my father endlessly trumpeted the cases in the media and in medical journals as proof of his claims,” Peter says. “I fact-checked all the cases and discovered that they ranged from dubious to outright fraud. For example, a couple of doctors who were the alleged rescuers in two of the ’miracle cases’ just happened to be longtime buddies of my father, a fact that none of them disclosed.”
One of those was Esch, according to Peter, who says he received verbal confirmation in 2005 that Esch knew Heimlich for many years before the time of the rescue described in JAMA. Esch died in 2010.
Recent Heimlich studies
Today, Heimlich is 91 years old. Due to his advanced years, Aquatics International did not contact him for this article. He has never backed down from his claims. But no reputable medical organization supports the use of abdominal thrusts as a rescue technique for drowning.
“When you go back and look at it, there is absolutely no science to show that it’s beneficial,” notes Dr. Peter Wernicki, the Aquatics Sub-Council chair of the American Red Cross Scientific Advisory Council.
The American Red Cross Advisory Council on First Aid, Aquatics, Safety & Preparedness published a scientific review, last updated in 2009, that recommends CPR as the first and only course of treatment for the resuscitation of victims.
“Subdiaphragmatic abdominal thrusts are neither effective nor safe methods for attempting water removal from the airway or lungs of drowned persons,” the ACFASP Scientific Review states. “No scientific literature supports the idea that aspirated water obstructs these patients’ airways thus hindering ventilations. Since no scientific study has shown water can be removed from a drowned person’s airways or lungs through subdiaphragmatic abdominal thrusts, the 2005 COSTR Guidelines remain the CPR treatment standard for drowned people.”
The review also points out that the use of the Heimlich actually could be detrimental. That’s because it delays implementation of CPR, which everyone agrees is proven effective. Plus, the pressure on the abdomen may cause a victim to aspirate vomit into the lungs, says Wernicki, also the medical adviser to the United States Lifesaving Association, and a member and past chair of the International Lifesaving Federation Medical Committee.
“Any attempt to remove the water from the airway is unnecessary, will delay CPR, hamper the correction of a drowned person’s hypoxemia [extremely low blood oxygen pressure], can induce vomiting, and may cause visceral or vascular injuries to the drowned person,” reads the ACFASP statement.
The statement cites research published in JAMA by Dr. James Orlowski which describes a case study of a 10-year-old boy who was given the Heimlich maneuver after being submerged. The child vomited, which damaged his lungs and hindered rescuers’ efforts to perform CPR. The boy later died.
Orlowski notes that the Institute of Medicine also came to the same conclusion that the American Red Cross did. Jeff Ellis & Associates Inc. of Ocoee, Fla., which did include the Heimlich maneuver in its protocols starting in 1995, now follows the medical agencies. It dropped the use of the Heimlich in 2000.
Still, in 2010 Hunsucker published a report in the International Journal of Aquatic Research and Education, which explains NASCO’s position. He followed that report last year with a public statement. But medical experts and reports in the popular media have continued to question NASCO’s practice.
NASCO was founded in 1974, and the current protocol has been in place since the mid- to late 1990s, according to the 2010 IJARE report that Hunsucker co-authored with Scott Davison, vice president of development at NASCO. Hunsucker holds Ph.D.s in mathematics and engineering.
NASCO’s protocol has six major parts: scanning, victim identification, moving to the victim, in-water intervention (IWI)/removing the victim from the water, out-of water intervention (including CPR), and management, as described in the paper. The Heimlich maneuver comes in as an in-water intervention technique, defined in the paper as “applying a resuscitation procedure in the water, immediately after contacting a drowning victim.” The company advocates the use of five (and only five) abdominal thrusts in cases of short-duration submersion (one minute or less), while the victim is still in the water. That procedure should be followed immediately by extricating the victim from the water and performing CPR according to American Heart Association protocols.
“These thrusts delay extrication between four to six seconds,” NASCO stated in the open letter on the subject, dated Oct. 30, 2011.
“The intent of these thrusts is to begin to initiate respiration.”
To define the effectiveness of NASCO’s use of the technique, Hunsucker and Davison’s IJARE report analyzed data from
waterpark client rescue reports dated between 1999 and 2009. These included 56,000 rescues and 32 respiratory failures resulting in four deaths.
Those findings show that the NASCO protocols including the use of abdominal thrusts resulted in restored spontaneous respiration in approximately 87 percent (28) of respiratory failure victims. Spontaneous respiration was restored using just IWI in 14 (nearly 44 percent) of the 32 respiratory failure cases, and abdominal thrusts done out of the water restored spontaneous respiration on two other cases.
The ongoing dispute
NASCO has received a significant amount of criticism for its position recently.
In 2009, three fatal drownings at NASCO facilities raised the issue of NASCO’s use of the Heimlich in the popular media. Last year, the Northern Virginia Park Authority eliminated the use of the Heimlich in its lifeguard rescue protocols after a story in the Washington Post made the general public aware that the technique had been discredited by the medical community as an acceptable protocol for drowning resuscitation.
“All of us in the emergency medical field — whether first responder, EMT, paramedic, whatever — are not the ones who set the protocols. The protocols are set by medical experts, and it’s our job to follow those protocols. Period,” says B. Chris Brewster, president of USLA. “If, for example, a paramedic is involved in some sort of emergency intervention and takes actions that are inconsistent with the protocols, it’s a major violation of professional ethics.”
The question of ethics was raised by respected experts, including Wernicki, Peter Chambers, Roy Fielding, Terri Lees, David Markenson, Francesco Pia and Linda Quan, in rebuttal to NASCO’s IJARE article. The rebuttal, published in IJARE in 2011 stated that “the study failed to adhere to all three recognized principles of human subject research — autonomy, beneficence, and justice. …”
“The study was ill-conceived and poorly carried out,” Wernicki summarizes. “The purported outcomes do not support the conclusions stated. The review of the literature is incorrect and misleading. It unethically subjected thousands of children and adults to a universally condemned procedure. It had no oversight or approval by any scientific board. It was performed on unsuspecting subjects who never gave informed consent. The study authors had significant conflicts of interest and potentials for bias.”
For his part, Hunsucker continues to maintain the position that abdominal thrusts work as an in-water intervention technique that is a small part of the overall NASCO response protocol. He points out that NASCO’s drowning rate of 0.00635 per 100,000 compares favorably with the CDC estimate for all pool drownings of 0.6 per 100,000.
He answered the questions over ethics in a response to the rebuttal article, noting, “This was particularly interesting since one of us teaches professional ethics at the university.”
In a letter to Aquatics International, he also notes that “most other major organizations have not made any significant improvements in their protocols associated with drowning since the inception of CPR in the middle ’70s.”
While it’s case closed on the Heimlich maneuver for most, few are likely to deny that continued drowning research and review, appropriately conducted, can only help to save lives. For now, that is perhaps the one point of common ground.
As Hunsucker wrote to Aquatics International, “It is time to move forward and find even better methodologies to deal with the tragedy of drowning.”