Heimlich's Maneuver

Henry Heimlich is Ohio's most revered doctor. He may also be the most dangerous. Ask his colleagues -- and his son.

On June 22, 1980, the doctor presiding over the otherwise tranquil emergency room of Lima Memorial Hospital saved the life of a two-year-old girl. In so doing, Dr. Edward Patrick rewrote medical history.

Erin Snow had fallen into the water after her parents' raft capsized on Mirror Lake. She had been underwater for 20 minutes, and it took 20 minutes to get her to the Lima hospital, according to an article Patrick wrote about the case.

By the time she arrived at the emergency room, Patrick notes, Erin was in full cardiac arrest. He recalls that mouth-to-mouth resuscitation by paramedics had no effect. He inserted a tube through the girl's mouth, but could draw water only out of her windpipe -- not her lungs. Having exhausted all else, Patrick tried something radical: the Heimlich maneuver.

After a single thrust, "Water gushed into and out the endotracheal tube," Patrick writes.

Based on his success, Patrick declared that "the Heimlich maneuver should be the first treatment for an unconscious drowning victim," replacing CPR. Dr. Henry Heimlich cited the article as proof that his maneuver works wonders on drowning victims.

The maneuver's use for drowning violated much of what was accepted as scientific fact. No matter, Heimlich had already clashed with the medical establishment in the mid-'70s, when he proposed the maneuver for choking in place of backslaps. He wanted the drowning franchise -- and to this end, Patrick's article was invaluable.

There are, however, two significant details that Patrick neglected to note in his article: first, that he was a close friend of Heimlich's. Second, that in reality there was no miracle at Mirror Lake. Erin Snow slipped into a coma that day and died four months later.

In the 24 years since the Erin Snow case, Heimlich has lobbied vociferously for his maneuver's use in drownings. As a branding manager seeks market share, Heimlich hawked his maneuver for a wide range of medical problems. He didn't want to be a one-hit wonder.

Medical experts united against him, arguing that the Heimlich maneuver was not only ineffective, but potentially lethal. They say the same thing today. Heimlich pushes on, furiously insisting that CPR advocates are condoning a veritable massacre -- 1,000 dead kids a year -- by not employing his maneuver at beaches and pools.

If he's been routed at scientific conferences, Heimlich still gets a warm reception among the unscientific, including the nation's biggest private lifeguard-training company, which defied prevailing wisdom by instituting Heimlich's maneuver at pools coast to coast. And his celebrated name allowed him to take his advocacy to the national media, circumventing the medical establishment.

Only recently has his persistence begun to appear dangerous -- especially when it concerns drowning victims.

That neither Heimlich nor Patrick can confirm basic facts about their landmark case only raises more questions.

An interview with Patrick does, however, turn up another startling revelation. Patrick claims to be the co-inventor of the Heimlich maneuver for choking and says that his contributions have been covered up by Heimlich himself, who wanted sole credit.

Now 84 years old and still a towering figure in Cincinnati, Heimlich stands to lose the thing he cherishes above all else: his good name.

It is natural for a son to be curious about his father's career, especially when that father is Dr. Henry Heimlich, whose accomplishments have received increasingly critical examination over the last several years. Less natural is Peter Heimlich's reaction. He does not seem to trust his father.

"Do I think the Lima case is fraud?" he says. "Let's put it this way: There are so many disparities between Dr. Patrick's article and the Erin Snow case, it doesn't look good. If the case is the way Ed and my father say it is, they should produce documentation and talk openly about it."

Dr. Heimlich refused to be interviewed for this story.

Patrick speaks, but for someone with a miracle case on his résumé, he is strangely guarded. He refuses to provide names of other doctors who participated in the case. He refuses to release work records that would prove he was actually working in the Lima Memorial ER at the time. And he refuses to furnish a hospital report from the Erin Snow case. All Patrick offers is his word.

"Let me just tell you that the documentation is there," he says. "Let's accept that, okay?"

It's odd, too, that this trailblazer made so few impressions in the small medical fraternity of Lima. Coroner Bill Noble has worked with the entire roster of the town's doctors and remembers them clearly. He doesn't remember Patrick. Nor does Ginny Keeran, the head ER nurse in 1980. She vaguely remembers his name, but nothing more. Lima Memorial Hospital refused to release his work records.

The ambulance run sheet from that day contradicts Patrick's claim that 40 minutes passed between the child's submersion and her revival. In fact, the run sheet places Mirror Lake nearly across the street from the hospital.

Linda Quan, a University of Washington researcher recognized as one of the world's leading authorities on drowning, deems the Lima case "highly questionable."

Usually, when a case study is biased -- or shown to be fabricated -- the motive is profit. A pharmaceutical company, for example, wants to demonstrate that its drugs work, and it's willing to cheat to do so.

In the Erin Snow case, profit wasn't a factor, but as the man behind the technique, Heimlich had much to gain.

Says Dr. James Orlowski, a drowning expert who spent 19 years at the Cleveland Clinic before moving to Tampa: "He has a personal investment in this whole thing, and he's taken a rather disingenuous approach to it."

Still, the medical field did not initially suspect fraud. It just dismissed Patrick's article as error-ridden and Heimlich's endorsement of it as foolhardy.

"The science behind it was totally bogus," says Orlowski. He and other national experts contend that Heimlich operates on a fundamentally false premise: that water fills the lungs and blocks the airway of drowning victims.

Instead, studies show that the moment water threatens to surge into the lungs, the vocal cords shut, a response called laryngospasm. A person has about two minutes before laryngospasm expires, after which water may flow into the lungs. But research has shown the water doesn't stay there to block the airway. Rather, it is absorbed by tissue and passes into the bloodstream.

Hence, revival depends on ventilation, not on removing water. A near-drowning victim who received the Heimlich maneuver would almost certainly vomit, but experts say that does little to aid breathing. Worse, the sheer mess of a vomit-covered face might discourage rescuers from performing mouth-to-mouth resuscitation. And in drowning rescue, mere seconds of delay could make the difference between full recovery and brain damage or death.

The other concern is that vomit may come up, only to go back down into the victim's lungs. "The stomach contents are acid," says Orlowski, "so it's like pouring acid into your lungs. Acid doesn't belong there . . . It essentially eats the lungs."

Finally, since some drownings occur after a head or neck injury, performing the Heimlich maneuver might compound spinal damage.

With science stacked against it, and with only a single flimsy study to support it, the nation's experts considered the Heimlich maneuver dead on arrival.

But his opponents underestimated Heimlich's power of persuasion as well as his persistence.

"In my experience," says Peter Heimlich, "he cannot hear the word 'no.' Sometimes it's good to be resolute, but this is something different."

Once every six years, the American Heart Association convenes leading researchers to consider how advances in science can serve the many health concerns under its purview.

By 1985, Heimlich had enough influence to land a seat on the association's Special Situations Committee. The stakes were high. If Heimlich succeeded in convincing the panel that his maneuver worked for drownings, lifeguards the world around would adopt his technique at beaches and pools. At his side was Dr. Patrick.

The pair cited Patrick's Lima case, as well as a case involving Dr. Victor Esch, another friend of Heimlich's who claimed that he, too, had saved a drowning victim by using the Heimlich maneuver in 1974.

But since Esch's case was never reported in a medical journal, it had even less credibility than Patrick's.

What he lacked in scientific evidence, Heimlich made up for in hubris. Transcripts from the meetings show Heimlich battling with University of Florida researcher Dr. Jerome Modell, one of the world's foremost authorities on drowning. Modell was backed by thorough, objective research; Heimlich by Patrick's case and little else. Nonetheless, Modell acquiesced, conceding that the Heimlich maneuver could be performed second -- if CPR failed.

Still, Heimlich insisted that his maneuver should be the first response. The final decision rested with the committee chair, Dr. Joseph Ornato. In letters Ornato wrote to Heimlich, he says that the night before he was to pass judgment, Heimlich confronted him, threatening that if he didn't get his way, he would "go to the media."

Ornato struck what looked to be a compromise. He kept CPR as the first response, but mentioned the Heimlich maneuver's use in those cases where a solid object, like food or sand, obstructs the airway, or if CPR fails.

Heimlich was furious. In one letter he told Ornato that "your recommendation of August 5 condemns the drowning victim to die due to water in the lungs rather than performing the Heimlich maneuver to expel water."

In his next letter, Heimlich drifted into conspiracy theory. "It is now clear there has been a secret conference." He charged that the decision was a "furtive process" between Ornato and his "collaborators" on the committee. He even scolded Ornato for using the term "subdiaphragmatic thrust" instead of "Heimlich maneuver."

Admiral Alan Steinman, the U.S. Coast Guard's water-safety specialist and a committee member, doesn't remember collaborating. "There were no secret meetings. We didn't say, 'We've got to get Heimlich.' That's crazy. It was simply a matter of 'Here's what science shows, and Heimlich is advocating something that isn't supported by studies.'"

In the end, Heimlich still earned a partial victory. His maneuver was listed in the American Red Cross's protocol, which meant that lifeguards would be ready to use it after CPR. Patrick's Lima case is cited as evidence.

Ornato attached another qualifier, noting that the effect of the Heimlich maneuver had not been properly studied, and until it was, it ought to be used sparingly. Ornato refused to comment for this story, saying that he was leery of further rancor with Heimlich.

But upon leaving the conference, Modell was determined to resolve the debate objectively. He and a colleague, Dr. Richard Melker, received funding to study the maneuver on dogs.

"Dr. Heimlich called me and volunteered to help me," recalls Modell. But that collegial attitude didn't last. Before Modell's study began, Heimlich held a press conference. He held a cocker spaniel for television cameras, dunking its head into an aquarium to demonstrate the cruelty of Modell's study. Heimlich condemned the drowning of dogs to prove what was, to him, self-evident: that the Heimlich maneuver worked.

He also notified People for the Ethical Treatment of Animals and sent a letter to the University of Florida newspaper. The effect was a campus seething with protesters, the most avid of whom called in bomb threats to Modell's lab and death threats to his home. It remains a chilling memory for the doctor. "I don't want to get into the details of that," he says. "I don't want to start another war." Modell dropped the study.

In a match between the two schools of science, Heimlich brought an extra weapon -- politics, the emotional kind. "The reason that we were willing to do it in the first place was to pacify Dr. Heimlich," says Modell. "And then he prevented it from happening."

Heimlich won the skirmish with Modell, but he was fighting wars on multiple fronts -- one of them in Cleveland, where Orlowski dealt a crushing blow to Heimlich's promotional campaign.

In a study published in the Journal of the American Medical Association, Orlowski reported on a 10-year-old boy who was submerged for between one and two minutes. It should have been a "routine resuscitation," Orlowski wrote, except that the lifeguard gave the child the Heimlich maneuver first.

The boy vomited so much that it was hard for the lifeguard and a physician to perform CPR. Some of the vomit made its way to his lungs.

Orlowski wrote that, given all the variables, CPR would have given the boy a 90 percent chance of recovery. Instead, he slipped into a coma and died in a nursing home seven years later.

Again, Heimlich retaliated, authoring a letter that the journal's editors deemed unfit for publication. Orlowski saw it. "He called me a liar and said I was totally unscientific and didn't understand how important his maneuver was."

Orlowski has tracked cases in which the Heimlich maneuver was used. His data shows that it was destructive in the rescues of more than 30 victims. But even with overwhelming evidence on his side, Orlowski admits the difficulty of battling Heimlich's star power. "That's what he's been bargaining on for years," says Orlowski. Even if scientists recognize the dangers, Heimlich remains persuasive to lay persons. "We still see cases where parents and well-meaning individuals perform the Heimlich maneuver," says Orlowski. "The child immediately vomits, and that creates all kinds of problems."

Orlowski calls Heimlich an "obstructionist" who chooses self-interest over ethics. "His approach has been to prevent the studies from ever being done, so nobody can get an answer to whether he's right or wrong."

Having followed the debate himself, Peter Heimlich sides with detractors. "This isn't theoretical," he says. "These are life-and-death issues . . . I don't think it's asking too much for him to substantiate his own case reports, instead of attacking anyone who dares to ask any questions."

By the early '90s, Drs. Heimlich and Patrick had become notorious among drowning experts. But Heimlich's lobbying efforts -- inside the medical community and with the popular press -- had begun to pay dividends.

In 1993, they were invited to give a presentation to the Institute of Medicine, the governing body of American health care. They bombed.

Dr. Linda Quan, who made a presentation to the same committee, remembers the looks on the faces of oncologists who heard Heimlich and Patrick describe the impossibility of ventilating through fluid, a feat doctors accomplished with newborn babies every day. Quan chuckles at the memory of Heimlich and Patrick's desperate attempts to win over the nation's sharpest medical minds by illustrating their theory with cartoons that violated elementary science.

Even stranger, reports from that meeting indicate that Heimlich and Patrick changed the two-year-old drowning victim in Lima from a girl to a boy.

"The Institute of Medicine is the crown jewel of medical intelligentsia in the United States," says Admiral Steinman. "They looked at this issue and said, 'Bad idea.'"

Though his science failed to impress, Heimlich's name still worked, and he had a winning way with reporters.

In 1993, John Eckburg of the Cincinnati Enquirer authored a column in which Heimlich argued that his maneuver would have saved a local girl who drowned in a municipal pool. Other articles in his hometown paper gave him the chance to claim that thousands of people die annually because CPR was being used instead of his technique.

That same year, the Associated Press relayed his accusation that the American Red Cross had falsified a study. Heimlich also performed his maneuver for NBC Nightly News. The Heimlich Institute website highlights appearances on The Today Show and Live With Regis and Kathie Lee.

Meanwhile, undaunted by his defeats at the highest levels of medicine, Heimlich attacked those same authorities in his talks before lifeguards. One 1995 speech was called, "Why do they lie and let children die?"

That year, Heimlich was given the chance to address the United States Lifesaving Association's board of directors. President Chris Brewster remembers Heimlich boldly calling on lifeguards to perform his maneuver, even though Red Cross guidelines said the exact opposite.

Brewster raised his hand. "I made the point that it would be a violation of our ethics to do this. Heimlich's response was 'That's what the Nazis said at Nuremberg.'"

Suddenly, Brewster found himself pitted against a world-famous scientist, fighting for the minds of his fellow lifeguards.

"It's the most nefarious part of what he's doing," says Brewster. "Recognizing that he will be unable to convince the medical authorities of the efficacy of his procedure, he is trying to go around them to impress upon nonscientists and tell them to ignore what they're taught.

"It's really despicable, in my opinion. When you have someone with that name who has saved thousands of lives, it's hard for the first-aider to assume that what he says is flawed. It's like 'Why would an icon in the medical world steer me wrong?'"

Heimlich's name was apparently enough for Jeff Ellis and Associates, the nation's largest private lifeguard-training company, which supervised nearly every waterpark in the country, including Cedar Point and Six Flags. In 1995, after lobbying from Heimlich, Ellis began teaching the maneuver as a first response.

It wasn't until four years later that Pamela Mills-Senn, a freelance reporter for Fun World, a waterpark trade publication, was assigned an article about the issue. She says Heimlich mailed her a packet of articles by leading experts like Drs. Linda Quan and Jerome Modell. But he only included fragments of articles -- not the full studies. The omissions made it seem as if he had the backing of medical leaders.

To Mills-Senn, the material looked fishy. Upon calling Quan, Modell, and others whose work was cited, she learned they were staunch opponents of the Heimlich maneuver. Quan and Modell say that, over the years, Heimlich has made a habit of misinterpreting their studies to support his theory.

When Mills-Senn asked Ellis to show her the medical evidence that led him to make such a dramatic change in rescue procedure, Ellis sent her a packet identical to the one she received from Heimlich.

"I was some unknown trade writer," says Mills-Senn, "but that was exactly the point: If I saw this on the surface, why didn't [Ellis and Associates] have the basic level of scrutiny?"

Not long after Fun World mailed copies of Mills-Senn's arduously researched article to subscribers, Ellis dropped the Heimlich maneuver and went back to CPR. Michael Oostman, an Ellis spokesman, insists that, despite the reversal, performing the Heimlich for five years was "not a mistake." But he refused to release the company's statistics on drownings during those years.

Despite scientific condemnation, Heimlich's public campaign continues. His website, www.heimlichinstitute.org, still wages war against CPR. "Media articles frequently report CPR was used by rescuers before children died of drowning," he writes in one indictment.

But what mortifies opponents is that, for all the research they have to disprove Heimlich's theories, his celebrity is still convincing to the general public, who are more likely to be at a drowning scene than a physician versed in Red Cross protocol. "What can you do?" asks Admiral Steinman. "He's completely off the reservation . . . but you can't compete with the guy who can go on television and make these kinds of claims."

Countering Heimlich's claims is someone known as "Holly Martins," a pseudonym alluding to a character in the 1949 thriller The Third Man, about a man who learns that his friend is a crook, then helps police catch him.

The modern Holly Martins shadows Heimlich via a website -- www.heimlichinstitute.com -- holding a giant store of documents, the upshot of which is that Heimlich has perpetrated a 30-year medical fraud. Martins's crusade culminated last fall in a letter circulated at the highest levels of American medicine, as well as at Deaconess Hospital of Cincinnati, the current home of the Heimlich Institute.

Drowning experts who have seen the site credit Martins for thorough research and say that, as best they can tell, Martins's evidence is legitimate. Lending more credence to Martins's claims is the fact that his challenging of Heimlich's record has been met with silence from the Heimlich camp.

Bob Kraft, who handles media inquiries for Heimlich, refused to discuss the doctor's work. But Kraft was more than willing to talk about Martins, whom he calls a stalker. "He's attacked nearly every achievement of Dr. Heimlich's career," Kraft wrote in an e-mail to Scene. "All of these charges are untrue."

Kraft identifies several other pseudonyms believed to be part of the Martins campaign and says that "Dr. Heimlich is now pursuing legal means to stop him."

To gain a full appreciation for the power of Heimlich's charisma, talk to Lakewood's Dr. Gerson Carr, once a medical resident under Heimlich at Jewish Hospital.

"Aside from being an unqualified genius," says Carr, "he has trouble being appreciated for his full intellect and understanding."

Carr has reason to feel indebted. In 1980, he was an ex-con, having served prison time for drug trafficking in New Mexico. He pleaded guilty to charges of writing script for addicted patients, then administering the drugs.

It was remarkable, then, that Carr would go straight from jail to the lofty position of research director of the Heimlich Institute the year he was released.

It wasn't a strenuous job, he confesses. "We had a lot of very long conversations, and the bottom line is, we never really did anything scientific together."

But Heimlich was impressed by Carr's rhetorical flair. "He comes up with some things that are so off the wall, like 'Let's cure people of cancer by giving them malaria,'" says Carr. "You research it a little bit, but [Heimlich] liked me because I could make it sound logical."

Carr says that Heimlich blamed the American Heart Association's refusal to sanction his maneuver partly on anti-Semitism. "He was there when they stayed up till 3 a.m., debating what they could call the maneuver other than to name it for 'that Jew,'" says Carr. Asked whether he witnessed this himself, Carr says he got it secondhand from Heimlich, which was just as reliable. "I believe him. Everything he has ever said has been 100 percent on the mark."

Through Carr, it's possible to get a rare glimpse into the scientific deliberations within the Heimlich group. Asked how Heimlich approached the maneuver's use for drowning, Carr says, "He mostly thought he knew what was needed, and he didn't need to test it that much. He just wanted to start doing it on people."

In 1990, after 10 years at the Heimlich Institute, Carr was fired, a fate he accepted obediently. "There were some personal and family and sexual problems," says Carr, "and I was involved with that. I was guilty."

Nearly 15 years later, Carr still seems to worship Heimlich. "Most of the time, I considered him my father, and I still have a very great admiration for him," says Carr. "He is a great man."

To hear Ed Patrick tell it, Heimlich himself is less loyal to his protégés.

September 30, 1985, was supposed to be a day of shared triumph, as United States Surgeon General C. Everett Koop had scheduled a press conference to announce his endorsement of the Heimlich maneuver for choking. Patrick maintains that he and Heimlich worked like the Wright Brothers to invent the subdiaphragmatic thrust for removing food from the airway, though Heimlich got lone billing, first noted in a science magazine article in 1974.

On the day of Koop's announcement, Heimlich staged his own press conference in Cincinnati, while Patrick had his in Evansville, Indiana. Patrick fielded questions from reporters about his role in inventing the maneuver. "At 9:30, when the press conference was over, a reporter came up to me and said, 'I just talked to Dr. Heimlich, and he says he did it alone,'" says Patrick. He was stunned.

Asked to describe his role in inventing the maneuver, Patrick gives technical descriptions of two discoveries that were turning points, both of which he claims as his own. He has difficulty remembering Heimlich's contribution.

Nevertheless, there are no sour grapes. "I never asked him about that," says Patrick of Heimlich's solo claim to the maneuver. "I would like to get proper credit for what I've done, but I'm not hyper about it."

Still, he says that for the sake of accuracy, the technique ought to be called the Patrick-Heimlich maneuver.

Peter Heimlich remembers meeting his father's friend, Patrick, at their home in the early 1970s. "Ed was memorable because he had this big Elvis hairdo and sideburns," he says.

The pair spent long hours talking on the family's patio, meetings that Peter Heimlich now believes were about plotting the maneuver. It was a shock to learn that Patrick had a role. His father had never mentioned Patrick's connection. "It's conspicuous by its absence," says Peter Heimlich. "I feel like my father has kept this hidden from me."

Patrick says that he and Heimlich remain "pretty good friends." But while Heimlich is among the world's most recognizable medical names, Patrick toils in relative obscurity, overseeing the trauma center in Cape Fear, North Carolina.

Gerson Carr can forgive one of Heimlich's personality defects, since Carr believes he's used it productively. "There's no question he has what a psychologist would call an 'acquired narcissistic complex,' which is a God complex," opines Carr. "He might even agree with that himself."

On the contrary, Heimlich's public statements indicate that he is claiming to be not God so much as a saint. In his newsletter, Heimlich marvels at how he shares a birthday, February 3, with St. Blaise of Sebaste, a bishop known for saving a boy from choking on a fish bone. "I'm very moved," Heimlich writes. "I think it has to be fate more than simply coincidence."

Since being credited with the cure for choking, the doctor's ambitions have grown increasingly grandiose. As early as 1982, he was quoted announcing his intention to cure cancer and bring world peace, even if he had to run for President to accomplish it.

Heimlich's efforts to cure AIDS, Lyme disease, and cancer by giving patients malaria -- called malariotherapy -- have been condemned by the World Health Organization as charlatanism, yet Heimlich has persisted, advertising malariotherapy on his website and conducting experiments on people in China. He has sought to establish malariotherapy clinics in South Africa. One medical figure describes the venture as "beyond bizarre, beyond weird."

Though his name seems destined to remain in Webster's in perpetuity, Heimlich's legacy has taken a number of heavy hits recently. Last year, the Cincinnati Enquirer ran an article on Romanian surgeon Dan Gavriliu, who accused Heimlich of claiming credit for an esophagus-replacement surgery Gavriliu pioneered 40 years ago. Heimlich conceded only that Gavriliu must have developed the procedure at the same time.

Patrick's part in devising the maneuver strikes at the very foundation of the Heimlich empire.

Still, what seems to haunt Peter Heimlich most is the possibility that reports on the Lima rescue and others supporting his father's position are phony. The reluctance of Heimlich and Patrick to provide proof to the contrary only amplifies that fear.

"If fake cases were used to convince people to do the Heimlich maneuver on drowning victims, then a terrible thing has happened," says Peter Heimlich. "The best possible outcome is that the cases are proved real, because the alternative is unspeakable."

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