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?
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 those years,
my father engaged in an aggressive and tireless media campaign.
In hundreds of news stories and on national television (such
as this
1984 appearance on David Letterman's show), he claimed any
method except the Heimlich maneuver was ineffective or dangerous.
Then, in late 1985, US Surgeon
General C. Everett Koop took the unusual step of intervening.
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.
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 to include 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?
In other words, why did the
highest-profile Surgeon General in US history apparently use
his influence to attempt to manipulate national first aid guidelines
to benefit his old friend Henry Heimlich?
###
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 1982 Yale research study that allegedly
proved backblows were dangerous (more below), and other activities
designed to "win the choking rescue crown" as one writer
has said.
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's been my
father's closest associate for the past 30 years and was
involved in every aspect of the Heimlich maneuver. In May 2003,
Dr. Patrick's "Patrick Institute" issued
this press release in which he claimed to be the uncredited
co-developer of the maneuver. His choking research was never
published in a peer-reviewed journal, but here's
what's on the website of "The Patrick Institute":
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 equations,
at least one prominent public official was impressed. From Dr.
Patrick's website:
Dr. Edward Patrick wrote the surgeon
general Dr. C. Everett Koop (August
16, 1985 letter) 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 (September 19, 1985
letter) to tell him that he agreed with Patrick and would
so inform the American people.
Dr. Koop's 1985 letter to
Patrick makes for good reading:
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 (sic),
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 Surgeon General Koop
was unable to reach "Henry" (Heimlich), Dr. Koop clearly
went to considerable efforts to contact Dr. Patrick, including
five phone attempts. That would seem to confirm the claims by
Dr. Patrick and my father about how impressed Koop was with Dr.
Patrick's efforts.
Dr. Patrick also elaborates
on those calls and letters he received from Dr. Koop in this
excerpt from an April 20, 2007 Federal Court deposition.
(For more on Dr. Patrick's background and his relationship with
my father, don't miss the 2004 Cleveland Scene cover stories,
Playing
Doctor and Heimlich's
Maneuver.)
Curiously, in a recent letter,
Dr. Koop tells a different story about Dr. Patrick (copy of letter
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 the story hits
a roadblock. Koop won't answer that question. When someone tries
to ask, including reporters representing ABC News, the New Yorker
magazine, and Radar Magazine, Dr. Koop ignores them.
Is he unavailable or ill?
If this
recent video interview with "Ali G", the hip-hop
alter ego of comedian Sacha Baron Cohen (aka "Borat Sagdiyev"),
is any indication, Dr. Koop appears quite fit. He also maintains
a busy travel schedule. So perhaps he has other reasons for avoiding
reporters' questions about this subject.
As for Koop's preposterous
claim that backblows and chest thrusts are "hazardous, even
lethal":
1) For decades, the European
Resusciation 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)
In 1985, Dr. Koop used the
bully pulpit of the Office of the US Surgeon General to promote
a medical opinion which was unsupportable at that time. 20+ years
later, that opinion is now proven to be not only false, but tainted
by a variety of duplicitous activities orchestrated by my father.
How to proceed? At minimum,
Dr. Koop needs to 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).