In this exclusive series, freelance writer Pamela Mills-Senn tells the story behind some landmark investigative journalism she published regarding Cincinnati’s infamous Dr. Henry Heimlich.  In this third installment, she details the truth she came to see after digging through piles of medical research—including Dr. Heimlich’s medically unsound “Straw Argument.”

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Read Part Two:  “The Tides of Research Rising”
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When Quan returned my call, she confirmed that Heimlich’s extrapolation of her data was incorrect. Then she dropped another bombshell.

Remember that Heimlich claimed the children in Quan’s study had been given CPR by Red Cross trained lifeguards. He takes this a step further in his chapter stating that, “Lifeguards were not permitted (italics mine) to use the Heimlich maneuver, only CPR.”

All of this was patently untrue, said Quan.

She told me that the death rate for children pulled from the pools by lifeguards in her study was 42%. But she went on to tell me that these were lifeguards in the loosest sense of the word. They sold tickets and hot dogs, they manned the locker rooms, and contrary to Heimlich’s contention, they had received zero CPR training by any agency.

(Later, when I received her complete study, I saw where she stated, “[CPR] training and competency is not required for lifeguarding, but it should be.” In this same study Quan also said that the high mortality rate, “Reflects on the ability of the lifeguard to recognize, rescue, and resuscitate the drowning child.”)

These were the contributing factors behind the high mortality rate and why she advised that lifeguards receive CPR training, Quan told me during the first of what turned out to be many calls (and even more emails). And in fact, Quan continued, a later study she conducted demonstrated that an increase in CPR-trained guards was among the factors associated with a decrease in the number of drownings and near-drownings in this area.

(It’s also interesting to note that during the period of time covered by Quan’s study, the maneuver for drowning was not even an issue for rescue personnel so Heimlich’s assertion that guards were not permitted to use the maneuver appears to be a misstatement of the situation)

I was floored.

He does this all the time, she fumed, referring to Heimlich. She had told him and told him and insisted that he stop misrepresenting her work, but he continued to do so.

(OK, here’s where I start nutshelling, just to spare you word count. If you would like to see my original article—I warn you it’s close to 8,000 words—click here.)

Hazinski started sending me drowning research studies, as well as documents from the National Academy of Science (NAS) and the Institute of Medicine (IOM). Quan provided information as did a source at the Red Cross. And I continued to ask Heimlich for sources favorable to his cause, and to pester Jeff Ellis and one of his main guys at the time, Larry Newell, for information not only about how people drown, but why they decided to switch from using CPR to the maneuver.

In the end, between the materials everyone sent and the resultant interviews, correspondences, journal articles, emails, etc., I ended up with five well-stuffed file folders of information.

Until I started this project, I really hadn’t given much thought to how people drown—I just figured it wouldn’t be one of the ways I’d want to go. But I did think that when people drowned, their lungs completely filled up with water, and that this was in fact the very definition of drowning.

And this is Heimlich’s perspective. He says that in almost 90% of all submersions the victim inhales enough water to “fill the lungs.” He says it’s impossible to ventilate lungs that are filled with water. He also contends that the maneuver “clears all the water from the lungs,” even from the alveoli (microscopic air sacs within the lungs).

Heimlich supports his assertions in a variety of ways—most typically, I discovered, through creative interpretation of other researchers’ work—but also through his own efforts. For example, to demonstrate the difficulty of ventilating through fluid, he uses a straw, inserted into a container of water. Once, inserted, water fills the straw to the same level that it fills the container.

Placing a finger over the exposed end of the straw, he pulls it from the container. Heimlich explains that the water remains in the straw because of atmospheric pressure and surface tension. Blowing into the open end of the straw, through the water causes only a slight movement (the way mouth-to-mouth given to someone with water in their airway causes the chest to rise, he says) but no air reaches the finger. Heimlich says the straw mimics the lungs and demonstrated that air cannot pass through water.

I cannot tell you how nuts that illustration made Quan, Hazinski and others that I spoke with.

OK, here was my problem and also my motivation for all the phone calls I made, the countless papers/abstracts I read (with titles like “No Improvement In Pulmonary Status by Gravity Drainage or Abdominal Thrusts After Sea Water Near Drowning.” A study conducted by Peter Safar and Nicholas Bircher, both drowning experts) the mountains of emails I sent, the people—drowning researchers/experts, doctors, lifeguards, Coast Guard personnel, EMTs—that I tracked down, not to mention the sleep I lost for six months.

Ellis & Associates.

They had switched to the maneuver and yet no matter whom I contacted, and I started out by calling those whose research Heimlich had used to make his case, they all said the same thing—Heimlich had misinterpreted their research, some said this was deliberate, and that he was wrong.

Lungs do not fill up with water, they said. In most cases, because of something called a laryngospasm (this happens with a foreign object like water or food passes the vocal cords causing the larynx to spasm and close off. Example: when you take a drink and it goes down the wrong pipe and you can’t breath. This is what happens when a person is drowning) there is hardly any water in the lungs at all.

Plus, said the experts I interviewed, fresh water in the lungs is rapidly absorbed, creating an inability to recover any amount of water through drainage, suction (or the maneuver). What is left in the lungs is pulmonary edema fluid, which is very frothy and not easily expelled—not aspirated water that can be removed by the maneuver. Furthermore, they said, it is possible to ventilate through water. And I found no one that agreed with Heimlich that the maneuver could remove water from the lungs. The general consensus was, and still is, that if the maneuver does result in fluid being expelled, it is coming from the stomach.

The focus needs to be on ventilating people as quickly as possible, they said, something that administering the maneuver (until no more fluid is expelled, as Heimlich advises) could seriously delay, resulting in brain damage or death.

I asked Heimlich and also his associate Edward Patrick, M.D. who had worked with Heimlich to develop the maneuver, for more sources supportive of the maneuver. Heimlich provided a list that included several people who had been resuscitated with the maneuver. I didn’t call them because I wasn’t interested in talking with those untrained in drowning.

Another contact was, at that time, chairman of the National Swimming Pool Foundation, and I did interview him. As it turned out, he had no medical nor guard training; he just did research into the physical aspects of pool safety, such as building materials used, design, etc. Heimlich put me in touch with him because that organization also trained pool operators and Heimlich had approached him about endorsing the maneuver instead of CPR.

I was unable to reach either the fire commissioner (he would not return calls) or the lifeguard (he had moved) on Heimlich’s list.

He also suggested that I call Carol Spizzirri president of the Save A Life Foundation, based in Schiller Park, Ill. The foundation’s focus is to encourage bystander involvement in emergency situations and on public education. This was the one organization, other than Ellis, that endorsed responding with the maneuver first for drowning resuscitation. (More on this in part four)

Another source Heimlich put me in touch with was a retired surgeon and former chief surgeon of the Washington D.C. fire and police department, Victor Esch. According to Esch and Heimlich, Esch was the first to use the maneuver to revive a near-drowning victim. Esch told me he happened upon an unconscious swimmer being pulled out of the water by a guard.

“I don’t know what this guy ate before he went swimming but vomit and food was everywhere. There was just no way you could have done CPR on this person,” he told me.

Fair enough, and using the maneuver to clear the airway makes sense in this situation. In fact, few would probably argue against it. The only problem is, when Heimlich tells the story he leaves out the vomity details, preferring instead to say that after being given the maneuver, clear fluid was expelled, this fluid presumably being water and presumably coming from the lungs (according to Heimlich).

This is a significant discrepancy, and I asked Esch about this.

“I don’t know why Henry keeps saying that,” I recall Esch telling me. “I keep telling him not to.”

There’s more. Patrick suggested that I call a researcher in Canada who was working on a device that would administer the maneuver, rather than a person having to do it. I didn’t see how this figured into anything, but I called anyway. During our conversation (the details are not important for our purposes) he mentioned that his research indicated the number of choking deaths had stayed pretty constant since around 1955 to present (we spoke in 2000) meaning that there had been little decline in the numbers of folks dying from choking.

But, I asked, have you taken population increases into account? If you have, then the percent of choking deaths has certainly declined, which would therefore indicate that overall, fewer folks are dying this way.

Well no he hadn’t, he told me. “I guess I should have done that,” he admitted.

This was the caliber of researcher Patrick put me in touch with.

At the time, Heimlich was trotting around a young lifeguard to various presentations who had rescued two boys from a wave pool, resuscitating them with the maneuver. I called Nathan, who was 19 at the time of the incident. He was 21 when we spoke, in college and no longer guarding. True, he did use the maneuver to revive these kids, but when it happened, he was a first-time guard, he had never made a previous rescue, had never used CPR (he was initially trained in CPR but then Ellis switched their protocol) so therefore had nothing by which to compare. And he was on those kids in an instant when they got into trouble.

Here’s what happened. The youngsters had been seeing who could hold their breath the longest under water. Apparently, the competitive spirit got the better of them and they passed out. Nathan had been watching them from his guard tower and got to them immediately.

Now many drowning experts say that in very brief submersions—and since this was an Ellis-trained guard, and Ellis says the average submersion time for victims rescued by Ellis guards is around 29 seconds, it’s safe to assume the submersion time was short—the victims would probably not have inhaled any water and certainly not have experienced cardiac arrest. Some told me a slap across the face could revive people in this situation.

So, as nice as Nathan was, he hardly qualified as an expert spokesperson for the maneuver. I wondered, couldn’t Heimlich come up with anyone better?

I was starting to panic. The situation for Ellis & Associates was looking dire. No matter where I searched, medical support for the maneuver was hugely absent. Even more worrisome, if I could find all this out, surely Ellis could have. And if he did know this, why did he move forward with the maneuver? And if he didn’t know this, why didn’t he? Wasn’t he obligated to his clients to exercise responsible due diligence?

It wasn’t making any sense. 
About three months into my research, I called the editor, whom I had been keeping informed throughout. It wasn’t looking good for Ellis, I said. I haven’t been able to find any medical justification for what they’ve done.

I was worried this would ruin their business, I said. Do you want me to stop? Do you want to let this go? He didn’t. “We have to, we know too much not to,” I recall him saying

So that was that, and the dye was cast. And so I kept trying and trying to find a way to understand the decision Ellis had made. But it did nothing but get worse.

I asked Heimlich to supply me with the same materials he sent to Ellis, and I asked Ellis the same question. I was hoping this would turn up something different, something that would truly support the Ellis protocol.

Nothing.

I asked Ellis who was on their medical review board, the one responsible for making the decision. I asked Heimlich this also. It was comprised of folks that had PhDs in areas like engineering, mathematics and physical education (although they all had extensive background in water safety and some had worked with the Red Cross at one time, and at least one, other than Ellis, had an aquatic safety consulting company).

There was one M.D on the board; an emergency room doc that worked out of Rockford Memorial Hospital in Illinois. He was initially agreeable to an interview—until I emailed him a list of questions about his experience, how many drowning victims he had worked with, his concerns around CPR, why the maneuver was superior, etc. Upon receiving that list he refused comment.

But it seemed to me that a medical decision such as switching from CPR to the maneuver would have, or should have, required that more than one person on the board be a physician, and that this person should have extensive experience in drowning resuscitation.

All along I had been corresponding with Newell, who was initially a very patient and helpful Ellis source. But as my questions became more focused on data and details, I guess as I was moving through the research process and learning more, he became less agreeable. And I grew more confused.

In one email I asked him that if it couldn’t be assumed that CPR was responsible for reviving people, because their condition at the time was largely unknown (an issue discussed in an earlier correspondence) then by the same token, it could not be assumed that the maneuver was responsible for reviving people. He responded—in all caps.

So, Ellis was experimenting?

And in an earlier email, when I asked him if he could provide any well-known sources who could support the maneuver (telling him that I had a list as long as my arm of those who opposed it), he said he couldn’t.

“While there are some EMS system personnel who have concurred with Heimlich, he is actually a one-man show. There are no medical bodies I am aware of that endorse his position, only the folks you already know.”

I also ran across a copy of an article that appeared in an issue of Emergency Medicine News. I think this was a December 1993 or 1995 issue, I can’t be sure because the date is blurred. But in this article, entitled, “Debate Raging Over use of Heimlich in Drowning,” Newell, who has a PhD and was at the time manager for program development for the Red Cross National Healthcare and Education, was clearly opposed to the use of the maneuver for drowning, saying that,

“Dr. Heimlich knows absolutely nothing about our materials and our programs,” and that, “The Red Cross position is clear; We teach the consensus of opinion that’s stood the scrutiny of the peer review process.”

And yet now, just a few years later, he was aligned with Ellis and Heimlich, the latter of whom advises EMTs, lifeguards and others to ignore peer reviewed lifesaving processes.

I decided not to ask what had caused this change of heart; Newell wasn’t really my focus and besides, he had grown too testy, telling me that he was concerned about where the article stood, demanding to see it in its entirety prior to publication, and telling me that I no longer had access to any Ellis staff but him. The ranks had closed.

The article began to take a personal toll. I was constantly second-guessing myself. I became compulsive in my efforts to try and find support for the maneuver. Rather than working to prove Heimlich wrong, I was determined to find Ellis right. The implications seemed too fraught otherwise.

And all the while, in talking with doctors who had dealings with Heimlich throughout the years, I was warned. I would be sued. Heimlich had tried to derail the careers of many of those who had opposed him, I was told. There were implied physical threats (one Ellis cohort told me, and I remember his exact words, “If you’re thinking about going up against Ellis, you’re going to have people breaking down your door.”).

I asked my editor what kind of legal protection I could expect from the magazine.

Not much, he said.

I worried constantly that I would be sued, and wondered if this was fair to my (then) husband. Defending a lawsuit was simply beyond our financial means. My husband was sick of it all; he just wanted it over with. Our friends starting looking at me with all the fondness reserved for insurance salesmen and IRS auditors. Can’t you talk about anything else, they would fairly plead.

I remember the very last call I made before deciding it was time to wrap it up and start writing. Heimlich had faxed me an article from the Enquirer about a recent drowning. One of the detectives in the article was quoted as saying the victim’s lungs were filled with water—which is why Heimlich wanted me to see this.

I tracked down the detective in the article and read back that quote.

I never said that, he said. There wasn’t much water in the lungs.

In the end, I decided that I could research this forever and probably still never be comfortable. The editor and I decided that our focus needed to be on the materials Ellis used to make the decision, working from what they worked with, not trying to break any new ground. Were there unanswered questions that the scientific and medical communities needed to address about drowning? Yes, but that wasn’t our job, he said. Our concern was the waterparks and what they were doing now.

And here’s one thing I kept coming back to, and still do; a report generated by the IOM, who had been asked to (twice) review the drowning application of the Heimlich maneuver. After extensive review they found there was no reason to revise the ECC (Emergency Cardiovascular Care) guidelines in favor of the maneuver. One of the objections they raised about Heimlich’s work was the lack of valid data demonstrating the maneuver’s efficacy in near-drowning cases, although they acknowledged how difficult collecting this data would be. They said, “It is hard to imagine a research methodology for such a study that would or should be approved by a human studies committee.”

So, what in the hell was going on in the waterparks?  I wondered.  And I still do.

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Continue to Part Four:  “It’s a fun world after all”

Read Part Two:  “The Tides of Research Rising”

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1. .(JavaScript must be enabled to view this email address) says:
   10 May 2006  at  08:34 pm | #

   Finding out big truths like this is a heavy burden.  Perhaps that explains, in part, why certain media sources make no attempt to address the truth.  (Are you reading this, Mr. Callinan?  Where’s the story on Three Centurions?)

2. C. Everett Kook says:
   10 May 2006  at  10:06 pm | #

   Deano, Didn’t you write something last year about the Business Courier giving Heimlich an award?

3. .(JavaScript must be enabled to view this email address) says:
   11 May 2006  at  08:17 am | #

   Dr. Heimlich was called a “Lifetime Hero,” or something like that.

   Post resources to that event, if you’ve got ‘em!

4. Dagny Taggart says:
   11 May 2006  at  01:52 pm | #

   Courier’s Hero Article

   Silly goose!

   LtE Refute

   Courier Editorial

5. Quack Attack says:
   11 May 2006  at  03:15 pm | #

   Anti-Fraud Group: Is there Blood on the Heimlich Award Committee’s Hands?
   by Robert S. Baratz, President, National Council Against Health Fraud
   Cincinnati Beacon, Wednesday, January 11, 2006

   Open letter to Cincinnati Business Courier “Healthcare Hero” Award Judges:
   Sharron DiMario, John M. Rice, Ph.D, Julie Isphording, Barry Malinowski MD, O’dell Owens

   Recently we wrote the Business Courier to question the propriety of this award (copy of email below). Our argument was that under even mild scrutiny Heimlich has been engaging in illicit research on humans for years. We believe this includes applications of the “Heimlich Maneuver”, especially promotion of use of this for drowning and asthma. The entire story of some of the illicit experiments has yet to be told.

   The Business Courier did not include our concerns in their recent article, and these concerns remain. Heimlich has not produced evidence that any of his “studies” were legitimate, and relies on alleged case reports, attacking his critics, and bullying to advance his speculations. The data which refute accusations of misconduct have not been produced, but the evidence of the misconduct continues to build. A group of “spin masters” (spokespersons) have attacked his critics, but have not produced the simple papers that would prove them wrong. In the absence of such evidence, and considerable and growing evidence of wrongdoing, the obvious conclusion is that there was wrongdoing.

6. Caduseus says:
   11 May 2006  at  07:12 pm | #

   The contradictions here are disturbing. On one hand, it’s obvious that Dr. Heimlich’s methods are reckless and deceptive. His medical theories don’t appear to have any basis except that he says that they’re right. Plenty of people who act that way get institutionalized. Meanwhile the Business Courier gives him a “Healthcare Hero” award? WTF is going on here?

7. Caduseus says:
   11 May 2006  at  11:39 pm | #

   This isn’t hypothetical. Kids are dead because of Heimlich’s frauds.

8. .(JavaScript must be enabled to view this email address) says:
   12 May 2006  at  07:00 am | #

   From the article linked above:

   The paper said the instructor jumped into the water, braced himself on the rim of the pool and performed the Heimlich Maneuver on Henley.

   She was later pronounced dead at Northeast Regional Medical Center after doctors there were unable to revive her.

   “My daughter drowned at Truman, and I feel like the Heimlich had something to do with that.  I feel like she would have had a better chance if they had done CPR first,” said Henley.

   THAT’S why we are still carrying this story.  I know, we’ve talked about this drowning controversy for years—but it can put people’s lives at risk!  People might die due to the hack job theory of a LOCAL doctor!

   And Commission Phil Heimlich sits on the Board of the Heimlich Institute—which actuallyl encourages this stuff!

9. Quack Attack says:
   12 May 2006  at  01:46 pm | #

   For decades, the Heimlich maneuver for drowning rescue has been universally rejected as useless and dangerous by every legitimate medical authority. Who knows how many deaths have resulted from its use similar to the case above?

   The question remains, why does Deaconess Associations continue to teach and promote the Heimlich maneuver for drowning?

   Why hasn’t the Enquirer or other Cincinnati media reported this story or raised it as a legitimate question for Deaconess executives or Phil Heimlich, vice president of the Heimlich Institute?