The New Haven Register (nhregister.com), Serving New Haven, CT

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Red Cross reverses policy on choking aid

To smack the back or squeeze the trunk: That is the life-and-death question.

Monday, October 23, 2006

By Abram Katz

An older fellow in a steak house is staggering around soundlessly holding his throat and turning blue. He needs first aid before he asphyxiates.

For years, the American Red Cross recommended the abdominal thrust, a posterior hug with a fist just below the sternum, popularly known as the Heimlich maneuver.

This stand was supported in part by a 24-year-old study at Yale University, which appears to have been assisted by the object of the study, Dr. Henry J. Heimlich himself.

While critics of Heimlich cast doubt on the Yale study, Yale is the only institution that has conducted a follow-up investigation, and apparently no other institution has attempted to compare the effectiveness of the Heimlich maneuver to back blows.

Nevertheless, this year, the Red Cross amended its first aid instructions for choking by introducing the back blow.

The new recommendation is to first call 911 and then administer five sharp blows to the victim's back with the heel of the hand.

If the chewed lump of sirloin doesn't come shooting out of the hypothetical victim's throat, then proceed to five abdominal thrusts.

The American Red Cross has only a vague explanation for the change. "The Red Cross returned to the use of back blows, along with the use of abdominal thrusts, because the body of scientific evidence now states that the use of more than one method" is "most effective in helping a person who has an obstructed airway," said Pamela King, spokeswoman for the American Red Cross.

But since only about 3,800 people in the United States die annually from lodging food or other objects in their airways, scientists have not rushed to reveal the mysteries of choking, and the latest studies do not pertain to back blows.

In fact, the only known study comparing the Heimlich maneuver and back blow was performed by three Yale scientists: Richard L. Day, Edmund S. Crelin and Arthur B. DuBois.

The paper, published in 1982 in the journal Pediatrics, concluded that the Heimlich is superior. Back blows are not merely ineffective, they can force blockages down the throat and toward the larynx - exactly the wrong direction, the researchers concluded.

"Choking: The Heimlich Abdominal Thrust vs Back Blows: An Approach to Measurement of Inertial and Aerodynamic Forces," by Day, Crelin and DuBois, could well have been the final word.

Except that in acknowledgements at the end of the paper, the authors credit support from the "Dysphagia Foundation Inc. of Cincinnati Inc."

And records from the Ohio Secretary of State's office show that the Dysphagia Foundation was renamed "The Heimlich Institute" Aug. 30, 1982.

In other words, the Yale experts studying the Heimlich maneuver were apparently assisted by Dr. Henry J. Heimlich, developer and tireless promoter of the Heimlich maneuver. He referred to back blows as "death blows."

The connection between Heimlich and the Yale scientists appears to pose at least the appearance of a conflict of interest.

But DuBois, the only surviving author and professor of epidemiology emeritus at the Yale University Medical School, said Heimlich was not involved with the study.

The three scientists basically measured air pressure at the mouths of volunteers either receiving back blows or abdominal thrusts.

"Heimlich himself believed in the technique. He believed it was effective," DuBois said. "Some people feel that someone who vociferously recommends something that he invented (is) guilty of self-aggrandizement. Our lab work still stands up," he said.

Heimlich did not answer questions about the new Red Cross recommendations when he was contacted in his home in Cincinnati. He also did not return phone calls.

Yale's Day gave the "front versus back" question another crack in 1986. He showed that two back blows produced far less pressure or displacement of air than one Heimlich maneuver.

Day said that people who believed that a blow to the back would loosen a foreign object and jolt it out were "misled" and did not understand physics.

And there, for all practical purposes, the argument ends.

Day's papers and correspondence are archived in Yale's Sterling Library.

So why did the Red Cross return to back blows in the absence of any available published data? And why maintain abdominal thrusts in the face of findings showing that chest compressions worked better?

"The back blows utilize a jarring-type of effect on the object as the primary mode to move the obstruction," said King of the Red Cross. "The abdominal thrust does this by trying to create an artificial cough, using air pressure as the primary mechanism to move the obstruction from the airway," she said.

Stacey Lucibello, director of health services education for the Connecticut Chapter of the Red Cross, said, "Based on the 2005 consensus on science for CPR and emergency cardiovascular care, a combination of back blows and abdominal thrusts is more effective in clearing an obstructed airway than a single technique."