Why did US Surgeon General
C. Everett Koop manipulate national first aid guidelines as a
"buddy favor" for my father & Dr. Edward A. Patrick?
by Peter
M. Heimlich
"I have never been bought.
I cannot be bought. I am an icon, and I have a reputation for
honesty and integrity, and let the chips fall where they may."
- C. Everett Koop MD (New
York Times, September 5, 1999)
Back blows are "death
blows," Dr. Heimlich declared long and loud as he lobbied
for his maneuver's acceptance 30 years ago. In 1985, Surgeon
General C. Everett Koop endorsed this view, dubbing backslaps
"hazardous."...Peter Heimlich (says) "Koop was
an old friend of my father's, and he did it as a buddy favor."
(Maneuvering
Over Heimlich by
Lenore Skenazy, New York Sun/Creators Syndicate, 2/21/07)
SUMMARY: From 1974-1985, the medical community
was engaged in a protracted debate over which method was most
effective to save the life of a choking victim. Should rescuers
perform backblows, the Heimlich maneuver (abdominal thrusts),
chest thrusts, or a combination of these methods?
Before 1976, the American
Heart Association recommended backblows. From 1976-1985, the
American Heart Association and American Red Cross recommended
backblows as the first treatment; if the backblows failed, rescuers
should then proceed with the Heimlich maneuver. During that decade,
my father engaged in an aggressive and tireless media campaign.
In hundreds of news stories and on national television (such
as his 1984 appearance on David Letterman's show), he claimed
any method except the Heimlich maneuver was ineffective or dangerous.
(No legitimate evidence supported his claim, then or now. He
simply made it up and many reporters parroted it without question.)
Then, in late 1985, US Surgeon
General C. Everett Koop intervened in the ongoing debate. He
issued a public statement which echoed my father's claims virtually
word for word, saying backblows and chest thrusts were "hazardous,
even lethal." Koop's widely-reported statement, which included
no citations or evidence-based rationale as to how he arrived
at this opinion, urged the American Heart Association and Red
Cross to teach only the Heimlich maneuver. Further, Koop had
no expertise in emergency medicine. At the time, he told the
Washington Post that he decided to act after receiving letters
from my father and his close colleague, Dr. Edward A. Patrick,
who had done an unpublished study on choking.
Nevertheless, a few months
later, the two leading first aid organizations removed backblows
from their choking rescue guidelines. From 1986-2006, they recommended
the Heimlich maneuver and nothing but the Heimlich maneuver (with
exceptions for infants and pregnant women).
20 years later, both
organizations revised their guidelines and now recommend backblows
and chest thrusts. So why, two decades ago, did Dr. Koop
claim these methods were deadly? Based on what evidence? Why
did a Surgeon General use his bully pulpit to intervene and perhaps
help to stifle an ongoing scientific debate, one which involved
the public's right to the best available medical care? Why did
Dr. Koop attempt to influence US first aid organizations in a
field of medicine in which he had no expertise? When asked such
questions, Dr. Koop has refused to respond to inquiries, including
from several national media reporters.
Here's another good question:
Why didn't Dr. Koop or my father disclose that they had a longstanding
personal relationship prior to 1985? Further, in November 2008,
a Federal Court ruling supported a Cleveland newspaper's cover
story called "Playing Doctor" that raised serious questions
about Dr. Patrick's medical credentials.
In other words, why did the
highest-profile Surgeon General in US history use his influence
to manipulate national first aid guidelines to benefit his old
friend Henry Heimlich and apparently base his decision on unpublished
research by another doctor with problematic credentials?
###
After my father, Dr. Henry
Heimlich, introduced the Heimlich maneuver in 1974, determining
the best treatment for choking rescue became a subject of considerable
and often heated
debate in the medical community. During the next decade,
my father aggressively promoted the Heimlich maneuver over other
choking rescue treatments such as backblows and chest thrusts.
On national TV and in scores of articles in popular press, he
insisted those methods were not only useless, but could even
make the situation worse.
The lack of any legitimate
data to support his claims did not deter his mission to eliminate
all treatments except for the maneuver that included his name.
His determination was expressed
in a variety of unconventional tactics. For example, he enlisted
his personal secretary to
send phony letters to medical organizations and to the journals,
he threatened first aid organizations with potential lawsuits,
he
clandestinely funded a now-suspect 1982 Yale research study
that allegedly proved backblows were dangerous (more below),
and other activities designed to "win the choking rescue
crown" as one reporter put it.
On September 30, 1985, a powerful
advocate came to aid my father's cause. The Department of Health
and Human Services issued a
widely-circulated press release stating that US Surgeon General
C. Everett Koop was urging all first aid organizations to adopt
the Heimlich maneuver and eliminate all other choking rescue
treatments In fact, it read like something my father himself
had written:
"Millions of Americans
have been taught to treat persons who are choking with back blows,
chest thrusts and abdominal thrusts," Dr. Koop said. "Now,
they must be advised...and I ask for the participation of the
Red Cross, the American Heart Association and public health authorities
everywhere...that these methods are hazardous, even lethal."
A back slap, the surgeon general said, can drive a foreign object
even deeper into the throat. Chest and abdominal thrusts, because
they refer to blows to unspecified locations on the body, have
resulted in cracked ribs and damaged spleens and livers, among
other injuries. "The best rescue technique in any choking
situation," Dr. Koop said, "is the Heimlich Manuever."
Then in December, Dr. Koop
signed a
two-part Public Health Report published by HHS promoting
the Heimlich maneuver which was an elaboration of the earlier
press release. His report did not include any citations or explain
on what basis he arrived at his conclusions. It did, however,
include nonsense like this:
For years medical opinion
differed on the best way, or ways, of dislodging an object from
the throat of a choking victim. Sharp blows to the back, finger
sweeps of the throat and manual thrusts to the chest were methods
often recommended. Today, there is universal agreement that these
methods can be dangerous and should not be performed.
That last sentence is not
only false, it's illogical. If indeed there was "universal
agreement," then why did Dr. Koop need to issue a statement
making a pronouncement in favor of one side? Shortly thereafter,
in this
letter to the editor, American Heart Association committee
chairmen Joseph Greensher MD and William Montgomery MD made that
clear in their response to Koop:
The editorial "The Heimlich
Maneuver"...by C. Everett Koop, MD, ScD, Surgeon General...was
premature and misleading...Because pronouncements by the Surgeon
General carry great persuasion and are widely cited as authoritative,
it is imperative that the data conveyed be exact.
So why did Dr. Koop choose
to interfere in this particular debate? Why did he use the weight
of his office to interfere and influence an ongoing scientific
debate in a field outside his expertise? And why did he endorse
the Heimlich maneuver over other choking rescue treatments?
For one thing, Dr. Koop and
my father had a longtime pre-existing personal relationship,
a fact neither man has ever made public, but which Dr. Koop admitted
in a recent letter (copy on request):
I was a friend of Henry Heimlich
for a long time before 1985, but that had nothing to do with
my taking a position.
But let's take Dr. Koop at
his word and assume their friendship had no bearing on his actions.
On what scientific evidence, therefore, did he base his decision?
Koop answered that question
in this October
2, 1985 Washington Post article:
Yesterday, as the U.S. surgeon
general, Koop endorsed the life-saving Heimlich Maneuver "as
the only method that should be used for the treatment of choking
from foreign body airway obstruction" and prodded the American
Red Cross and American Heart Association to move more quickly
in adopting it exclusively...He urged that other methods be dropped
immediately as "hazardous, even lethal," particularly
the traditional use of sharp blows to the back that he said can
drive a foreign object even deeper into the throat. In doing
so, Koop jumped into the middle of a long-running controversy
in the public health community over the place of the Heimlich
Maneuver in first aid procedures.
The technique is named after
Dr. Henry J. Heimlich, a physician at Cincinnati's Xavier University
who developed the life-saving "hug" in the early 1970s
and has since widely promoted it as the best method of saving
a choking victim. But the health organizations who advise the
public and the medical profession on first aid have been slower
to adopt his stance and for the past decade have recommended
that four sharp blows to the back be attempted first before the
"abdominal thrust."
In July, after a national
conference reviewing their guidelines, the American Red Cross
and the American Heart Association made a joint announcement
that the advisory panel had recommended "exclusive"
use of the Heimlich abdominal thrust. Their press releases said
that the change was being made to simplify teaching of first
aid, but maintained that both back blows and the abdominal thrust
are effective.
Yesterday, spokesmen for both
groups repeated that view, saying that the recommendation on
the Heimlich Maneuver is still under review and is not expected
to be adopted officially until early next year. "Dr. Koop
and Dr. Heimlich are not giving the process quite the chance
it deserves," responded Red Cross senior vice president
Dr. Lewellys Barker.
Koop said in an interview
that he felt the need to act more quickly after receiving letters
from Heimlich and University of Cincinnati professor Edward A.
Patrick, as well as his knowledge of the value of the procedure.
"I felt that I couldn't stand around and wait." Patrick,
who has performed research showing that the back slap can drive
a foreign object downward, complained to Koop that the "lives
of many Americans are endangered as the result of Red Cross first
aid instruction" and said "it is urgent that you inform
the public through the media of the back slap danger."
Based on this article, apparently
Dr. Koop was motivated to write his PHS after receiving a letter
from my father and after reviewing Dr. Edward A. Patrick's research
on choking. In a
1993 Cincinnati Enquirer op-ed, my father agreed with that
conclusion:
Surgeon General Koop, impressed
by Cincinnatian Dr. Edward Patrick's study of 1,600 choking cases,
declared backslaps "lethal"....
Who is Dr. Edward Patrick?
As it happens, he was my
father's closest associate for 30 years and was involved
in every aspect of the Heimlich maneuver. For more on their relationship
and Dr. Patrick's colorful career, don't miss the 2004 Cleveland
Scene cover stories, Heimlich's
Maneuver and Playing
Doctor.
On May 28, 2003, the website
of "Patrick Institute" posted this
press release that included my father's name which identified
Dr. Patrick was the uncredited co-developer of the maneuver:
In the early 1970's the medical
community, for the most part, was not prepared to accept that
treatments could be evaluated using Statistical Pattern Recognition.
Instead, the medical community insisted that Double Blind Studies
were needed, but this was not practical in the case of choking.
Patrick indicated that any
outcome O could be evaluated for any treatment sequence Ti by
computing an estimate of the conditional probability of the outcome
O given the treatment sequence. Thus, one needed to estimate:
p(O|Ti), for an outcome O for each treatment sequence T1, T2,....
TN.
More precisely, one would
need a set of "training samples" x to learn or estimate
this outcome probability, so that the above expression should
be replaced by: p(O|Ti, x), for an outcome O for each treatment
sequence T1, T2,.... TN, given training samples for each treatment
sequence.
Using verified training samples
from cases sent into talk shows, Patrick was able to estimate
needed probabilities....the journals controlled by AHA researchers
could publish flawed "peer reviewed" papers while a
scientific paper on outcome analysis by Patrick was difficult
to publish....
Though "the journals
controlled by American Heart Association researchers" may
have failed to appreciate Dr. Patrick's mathematical approach
to determining the best method to rescue a choking victim, at
least one prominent public official was impressed. From the now-defunct
"Patrick Institute" website:
Dr. Edward Patrick wrote the
surgeon general Dr. C. Everett Koop providing Dr. Koop with the
literature and research studies so the United States Department
of Health & Human Services could independently review the
information. After reviewing the information, Dr Koop called
and wrote Dr. Patrick to tell him that he agreed with Patrick
and would so inform the American people.
Here's Dr. Patrick's August
16, 1985 letter and Dr. Koop's September 19 reply:
Dr. Koop's letter makes for
good reading (underlining from original):
Edward A. Patrick, M.D., Ph.D.
Department of Electrical and Computer Engineering
University of Cincinnati
Mal Location 30
898 Rhodes Hall
Cincinnati, Ohio 45221
Dear Dr. Patrick:
If you ever make a better
mousetrap, the world will have trouble finding your door.
I made five calls to the University of Cincinnati, trying to
reach you. Although there were some people who knew that you
existed, no one seemed to know where. Hence this letter.
All I wanted to do was to
inform you that I had taken some action in reference to the Heimlich
maneuver versus backslapping. I issued a press release on the
matter several weeks ago (a copy of which was mailed to you).
There will be a discussion of the matter in my monthly column
which appears in weekly newspapers throughout the country. Also,
the matter will be discussed in an editorial in the next issue
of Public Health Reports.
I called Henry's Office, found
he was in New York, but left a message.
Thank you for your letter.
It was very much appreciated.
Sincerely yours,
C. Everett Koop, M.D.
Surgeon General
Although the Surgeon General
was unable to reach "Henry," he clearly went to considerable
efforts to contact Dr. Patrick, including five phone attempts.
That certainly seems to confirm claims by Dr. Patrick and my
father that Koop was impressed with Dr. Patrick's contributions.
Dr. Patrick elaborates on
those calls and letters he received from Dr. Koop in this excerpt
from an April 20, 2007 Federal Court deposition:
Curiously, in a recent letter,
Dr. Koop tells a different story (copy on request):
I don't have a problem with
long-term or short-term memory, but I certainly do not remember
having any discussions with Dr. Edward A Patrick...To the best
of my knowledge, I did not use any analysis of Patrick's on 1600
cases of choking....
Curiouser and curiouser. Well,
if as Dr. Koop now says, he didn't rely on Dr. Patrick's
research, on what scientific evidence did the US Surgeon General
rely upon in his efforts to influence the Red Cross and the Heart
Association in favor of his old friend's maneuver?
That's where this story hits
a roadblock because when anyone tries to ask - including reporters
from ABC News, the New Yorker magazine, Radar Magazine, and other
news outlets - Dr. Koop refuses to answer the question. (By the
way, in spite of being in his 90s, Dr. Koop maintains a busy
travel and public speaking schedule, so he's fit enough to respond.
One can only assume he has other reasons for dodging questions
about this subject.)
As for Koop's unsupported
claim that backblows and chest thrusts are "hazardous, even
lethal":
1) For decades, the European
Resuscitation Council (ERC), the continental equivalent of the
American Heart Association, has taught backblows as the first
treatment for choking. ERC guidelines are followed by much of
the world. If backblows are "hazardous, even lethal"
as Koop claims, why aren't European choking victims dropping
dead or filing lawsuits against the ERC?
2) In December 2005, the American
Heart Association drastically revised its Foreign Body Airway
Obstruction (choking rescue) guidelines. The treatment recommendation
in the guidelines state:
Chest thrusts, back blows/slaps,
or abdominal thrusts are effective for relieving FBAO in conscious
adults and children >1 year of age, although injuries have
been reported with the abdominal thrust. There is insufficient
evidence to determine which should be used first. These techniques
should be applied in rapid sequence until the obstruction is
relieved; more than one technique may be needed.
3) In 2006, the American
Red Cross revised its choking rescue guidelines and now,
once again, recommend backblows as the first treatment for choking
rescue. The
Red Cross also recommends chest thrusts as part of the treatment
sequence.
4) In Australia, first aid
for choking rescue now recommends
backblows followed by chest thrusts.
5) Besides the previously
cited letters, in this 1982
letter to Richard Day MD my father refers to "Ev Koop."
This letter also indicates my father was soliciting Koop long
before his 1985 PHS, another fact which Koop apparently has never
discussed. Jason Zengerle of the New Republic told me that in
a recent interview, my father claimed he did not know Dr. Koop.
If everything was above board with him and Koop, why would my
father lie to a reporter? This behavior, combined with Koop dodging
reporters, raises obvious concerns.
6) Further undermining my
father's integrity, recent
articles in the New Haven Register, Columbus Dispatch, and other
publications report that my father and Dr. Day intentionally
misled the American Heart Association by failing to disclose
that Day's 1982 Yale "anti-backblows" research study
- which was presented to an AHA committee reviewing choking rescue
guidelines - was funded by my father. When informed of this duplicity,
the chair of the 1985 AHA committee stated:
There was never any evidence
here. Heimlich overpowered science all along the way with his
slick tactics and intimidation, and everyone, including us at
the AHA caved in. (Roger
White MD, Mayo Clinic, Cincinnati
Magazine, 4/07)
To summarize, in 1985 Dr.
Koop used the bully pulpit of the Office of the US Surgeon General
to promote one medical treatment over other treatments, not based
on research or legitimate evidence, but because of a personal
relationship. By tampering with the scientific process, he helped
block the medical community from identifying the best treatment
which, of course, prohibited the public from obtaining that treatment.
Further, his actions sowed confusion in the first aid community
that continues to this day. (See What's
the best way to rescue a choking victim? That depends on whom
you ask.)
How to proceed? Shouldn't
Dr. Koop either reaffirm - or revise - his position statement
on backslaps and chest thrusts?
For more on Dr. Koop's history
regarding public medical policy, interested parties may wish
to read, "Public
Health Profiteering" by James
T. Bennett (George Mason University) and Thomas
J. DiLorenzo (Loyola College).
Addendum
Rear Admiral Stephen K. Galson
MD MPH
Does the US Surgeon General's
office still support the medical opinion on choking rescue established
by Dr. Koop? On April 30, 2008, I wrote to Acting Surgeon General
Stephen K. Galson MD MPH to find out. Two months later (after
repeated nudging), I received his reply, a bureaucratic non-answer
that ignored my questions. Here's our correspondence: