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United States Lifesaving Association

PO Box 366 Huntington Beach, California 92648 Tel: 866-FOR-USLA www.usla.org

March 31, 2004

B. Chris Brewster

Jerry Gavin

David Shotwell

Greg Farry

Henry J. Heimlich, MD, ScD, President The Heimlich Institute 311 Straight St. Cincinnati, OH 45219-9957 Dear Dr. Heimlich, In 1995, American Lifeguard Magazine, which is published by the United States Lifesaving Association, carried an article which you authored, The Heimlich Maneuver First Step for Resuscitating a Drowning Victim. In the article, you recommended to our readers, who are professional lifeguards, For unconscious, nonbreathing drowning victims, perform up to five Heimlich Maneuvers, stopping when water no longer flows from the mouth. Almost all victims recover immediately, unless submersion was prolonged. Follow with CPR when necessary. It was thus your recommendation that lifeguards perform the Heimlich maneuver on drowning victims prior to initiating CPR and your assertion that almost all drowning victims will recover immediately, except in cases of prolonged submersion. Your article went on to state, Some lifeguards may be concerned as to whether they are obligated to follow American Red Cross recommendations Based on the evidence in this paper, I stand ready to testify that if a drowning victim dies and the Heimlich Maneuver was not the first treatment, that the treatment was inadequate. You thus encouraged lifeguards trained under CPR protocols maintained by the American Red Cross to ignore those protocols in favor of the protocols you advocated. You further stated that, Finally, all first aid, rescue and lifeguard training organizations agree that the Heimlich Maneuver should be used to save drowning victims. Your article credited discovery of the usefulness of the Heimlich maneuver in treating drowning victims to Victor Esch, MD, of Potomac, Maryland. You stated, In 1974 he watched as a lifeguard pulled a man from the water at Rehoboth Beach, Delaware, and declared the victim dead. Dr. Esch stepped forward and performed the Heimlich Maneuver on the man. Water gushed from the victims lungs and he immediately recovered. According to an August 28, 1974 article in the Washington Star-News, this rescue purportedly took place on August 14, 1974. The victim, Donald Urquhart

Duke Brown
Recurrent Representative

Eric Bauer
Liaison Officer

Tim Gallagher

Dr. Peter Wernicki

Medical Advisor

John Chip More

Legal Advisor

of Columbia, Maryland, was taken to Milford Memorial Hospital [Delaware] where he was treated for two days and then released. Your article in American Lifeguard Magazine included a footnote to a journal article authored by you which described this case (JAMA, 1975, 234:398-401). Your article in American Lifeguard Magazine included footnotes to three other articles authored by you, one of which was coauthored by Dr. Edward Patrick. All three articles describe a case in which Dr. Patrick purportedly used the Heimlich maneuver to revive a two year old drowning victim (Annals of Emergency Medicine, 1981, 10:476-480; Emergency Medical Services, 1981, 10(4):58, 60-61; Postgraduate Medicine, 1988, 84(2); 62-73). Although the name of the victim and other details were not included in your articles, it has been suggested to us that you and Dr. Patrick were referring to the case of Erin Snow, a two year old girl who was treated at Lima Memorial Hospital in Lima, Ohio, after a drowning accident on June 22, 1980. Recent information provided to us has raised questions regarding the factual basis of the Donald Urquhart and Erin Snow cases you have cited that purport to show the efficacy of the Heimlich maneuver for drowning. We have an ethical obligation to investigate and to correct the record, if necessary. We presume that you have personally reviewed corroborating evidence regarding these cases that validate your use of them as anecdotal evidence of efficacy of the Heimlich maneuver in drowning cases. In that regard, can you please: 1 . Provide the names of the physicians and hospital staff who treated Donald Urquhart at Milford Memorial Hospital, and who treated Erin Snow at Lima Memorial Hospital. 2. Provide hospital reports from both cases. 3. Provide the names of lifeguards and EMTs who participated in the Urquhart rescue. 4. Provide the names of ambulance personnel who participated in the Snow case and who will corroborate Dr. Patricks version of events. 5. Provide copies of EMT run sheets in both cases and a lifeguard report from the Urquhart rescue. 6. Provide a list of the people you interviewed in both cases to validate the facts you have cited. 7. Provide any clinical and anecdotal evidence beyond these two cases that supports your claim that when the Heimlich maneuver is used as a first step in drowning resuscitation, Almost all victims recover immediately, unless submersion was prolonged. 8. Provide any evidence you may have to demonstrate that, as you stated, all first aid, rescue and lifeguard training organizations agree [or agreed at the time of your articles appearance] that the Heimlich maneuver should be used to save

drowning victims." We are aware that Jeff Ellis & Associates, which once taught the maneuver, no longer supports its use by lifeguards. We are also aware that the International Life Saving Federation (of which we are a Full Member), composed of many of the national lifesaving federations of the world, does not support use of the maneuver as a first step in drowning resuscitation. We will protect the utmost confidentiality of the patients involved. Obviously, the names and facts in the Urquhart case have previously been made public, but if privacy is still a concern in either of these cases the appropriate records with names deleted would be acceptable. Prior to your article's appearance in our magazine, the Institute of Medicine issued a 1994 report which questioned the sufficiency of evidence supporting the use of the Heimlich maneuver for drowning, as well as the associated medical risks (Journal of Emergency Medicine, 1995, Vol. 13, No. 3, pp. 397-405). Among other concerns, the Institute of Medicine report cited a journal article by James P. Orlowski, MD which reported a drowning case resulting in death, in which a lifeguard apparently used the Heimlich maneuver prior to CPR in a drowning incident (JAMA, July 24/31, 1987, Vol. 258, No. 4). Subsequent to publication of your article in our magazine, an article appeared in Critical Care Clinics stating, in part, "We recently cared for a 3-year-old near-drowning victim who developed severe aspiration pneumonia following a bystander-administered Heimlich maneuver that resulted in regurgitation of stomach contents while the patient was still unconscious. Neurologic recovery was complete, but the patient succumbed to acute respiratory failure despite extracorporeal membrane oxygenation" (Critical Care Clinics, July 1997, Vol. 13, No. 4). Based on your reputation and the normal desires of both lifeguards and laypersons to take every reasonable effort to prevent death from drowning, it seems likely that a number of lifeguards and others have been persuaded by your article in our magazine to ignore CPR protocols they were taught and to instead follow your recommendations. While the article appeared some time ago, it has no doubt had an impression on many lifeguards and its recommendations are no doubt followed by some. Considering the significant public safety ramifications of this issue, we would appreciate your urgent attention to this matter. Please address your reply directly to me at: 1355 37th St., Suite 301, Vero Beach, FL 32960. Sincerely,

Dr. Peter Wernicki, M.D., Medical Advisor United States Lifesaving Association

encl: American Lifeguard Magazine article Washington Star-News article cc: Bryan Burklow, President, Deaconess Associations E. Anthony Woods, Chairman of the Board, Deaconess Associations Harvey V. Fineberg, MD, President, Institute of Medicine Augustus O. Grant, MD, PhD, President, American Heart Association Marsha J. Evans, President, American Red Cross Tracy Napper, Managing Editor , Annals of Emergency Medicine Peter A. Setness, MD, Editor in Chief, Postgraduate Medicine Carol Summer, Executive Editor, Emergency Medical Services Victor H. Esch, MD Edward A. Patrick, MD

April 19,2004

311 STRAIGHT STREET CINCINNATI OHIO 45219 513-559-2391 FAX 513-559-2403 heimlicli@iglou.com
www. heirriljchjnstilute.org

Peter Wernicki, M.D. Medical Advisor United States Lifesaving Association 1355 37 ,h Street, Ste. 301 Vero Beach, FL 32960 Dear Dr. Wernicki: Your letter of March 31, 2004, to me, was mailed in error to the American Heart Association. They subsequently forwarded it to me; therefore, my reply is delayed. You state that in 1995, American Lifeguard Magazine, which is published by the United States Lifesaving Association, carried an article I authored titled, ' T h e Heimlich Maneuver - First Step to Resuscitating a Drowning Victim". Before we address your criticism, let me remind you that the American Red Cross (ARC) had adopted the Heimlich maneuver for saving drowning victims ten years prior to that time and was actively teaching it. The sole difference between the ARC and myself was whether to use the Heimlich maneuver or mouth-to-mouth first. You later charge, "You thus encouraged lifeguards trained under CPR protocols maintained by the American Red Cross to ignore those protocols in favor of protocols you advocated." I am perplexed by your criticism since you elected to publish my article. It is apparent that the USLA also felt the need to inform its lifeguards of the alternative to the ARC protocol. Several years ago, the USLA invited me to lecture at their national meeting. Clearly, the USLA asked me to speak because they were anxious to have their lifeguards informed concerning use of the Heimlich maneuver, rather than CPR, as the first step in drowning resuscitation. In my lectures and scientific publications, I refer to the University of Pittsburgh study carried out by Professor Peter Safar and his associates, which proved experimentally in dogs, that four Heimlich maneuvers clear the water from the lungs. (Dr. Safar was an originator of CPR.) Am I correct in recalling that the president of the USLA endorsed using a mechanical suction device in attempting to remove water from the airway of drowning victims? The value of educating lifeguards to use the Heimlich maneuver as a first step, to remove water from the lungs of drowning victims, soon became evident. Subsequent to my presentation to the USLA, an official report stated that Ron Watson (then USLA Vice President) and several police officers attempted to resuscitate two-year-old Deshun R. who had drowned in a lake in Jacksonville, Florida. Little Deshun lay lifeless, not breathing, and did not have a pulse. CPR was administered immediately with no positive result. Mr. Watson picked the child up and performed several Heimlich maneuvers to expel the water. Water immediately shot from Deshun's mouth. Deshun survived and recovered completely. Mr. Watson said, "Before you try to provide oxygen to the victim,

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it makes sense to clear water from the lungs." {Consolidator, Nov. 1995) Since then, many lives have been saved by professionals and lay persons using the Heimlich maneuver for drowning victims. One is Terry Watkins, emergency medical technician and Chief of the Destin Florida Fire Department. As he reported, Watkins saw a man performing mouth-to-mouth on four-year-old Shawn A. "Shawn was unconscious and had turned blue," Chief Watkins said. Watkins had read an article about the effectiveness of the Heimlich maneuver on drowning victims. He performed the Heimlich maneuver three times. "Each time about a cupful of water came out of his lungs. The third time he coughed up white foam and started crying," Watkins said {Destin Log). The boy recovered fully. The rescue was especially sweet for Watkins, who, after years of pulling people from the water, finally was able to save a life {Northwest Florida Daily News'). Almost half of your letter refers to reports from two doctors, each of whom used the Heimlich maneuver to treat a drowning victim. These incidents occurred 25 to 30 years ago. Dr. Victor Esch, then Chief Surgeon of the Washington, D.C. Fire Department, was the first rescuer to save the life of a drowning victim using the Heimlich maneuver. Dr. Edward Patrick, is a highly qualified emergency physician. You state that recent information provided to you has raised questions regarding the factual basis of their reports. Who raised these questions and what evidence did this individual provide to support your charge? You then list six questions, filling a half page, requesting such obscure information as the names of physicians and hospital staff who treated the rescued drowning victims in the hospital, hospital reports, names of lifeguards and EMTs who participated, names of ambulance personnel who carried the patients to the hospital, EMT and lifeguard reports, a list of people interviewed, etc.. You surely remember that the incidents occurred 25 to 30 years ago. You have already copied your letter of March 31, to Drs. Esch and Patrick, and they can take action as they see fit. No one 1 have spoken to has questioned the factual basis of the cases reported by these doctors. In your letter, based on "recent information", you now raise questions regarding the factual basis of their reports. If you have any facts to support what you said, please share them with me promptly. Your other questions pertain to use of the Heimlich maneuver in saving drowning victims and what organizations support this method. In addition to individually documented Heimlich maneuver saves, the lifeguard organization you mention, Jeff Ellis and Associates, adopted the Heimlich maneuver as the first step in saving drowning victims on January 1,1995. This decision was made after Professor John Hunsucker of the University of Houston, and advisor to Ellis, conducted an extensive examination of scientific studies of drowning. Thereafter, Ellis lifeguards kept detailed records of each drowning incident. Over a five year period, all of the cases reported had been unconscious, non-breathing drowning victims. You ask for evidence for my statement that when the Heimlich maneuver is used as a first step in drowning resuscitation, almost all victims recover immediately unless

submersion was prolonged. That finding, originally based on individual reports, was confirmed by Ellis lifeguards. Ellis lifeguards reported they saved 80 drowning victims in the first two years after adopting the Heimlich maneuver as the first treatment for drowning. Only one of those 80 drowning victims required CPR. As Ellis lifeguards reported, the reason CPR was required in only one case is that the Heimlich maneuver, by pushing up on the diaphragm, not only cleared the water from the lungs, but jump-started breathing {TV's Inside Edition, July 25, 1997). Ellis & Associates continued using the Heimlich maneuver as the first treatment for drowning from 1995 through 1999, which involved 32,000 lifeguards responsible for the safety of 50 million swimmers annually. In the course of these five years, Ellis used the Heimlich maneuver to resuscitate 152 unconscious, non-breathing drowning victims. One hundred and forty seven of them fully recovered. This is a success rate of 97%. In contrast, university studies report that CPR, recommended for drowning victims since the 1960's, resulted in up to a 60% death rate. This shows the futility of blowing air into water-filled lungs. As reported in the Journal of the American Medical Association, July 4, 1986, the lungs fill with water in up to 90% of drowning victims. You ask for evidence for my 1995 statement, "... all first aid, rescue and lifeguard training organizations agree that the Heimlich maneuver should be used to save drowning victims". In 1986, the American Heart Association (AHA) Standards and Guidelines adopted the Heimlich maneuver for drowning resuscitation. They reaffirmed this recommendation in their AHA 1992 Guidelines, stating, "Therefore, a Heimlich maneuver should be used only if the rescuer suspects that foreign matter is obstructing the airway or if the victim does not respond to mouth-to-mouth ventilation. Then, if necessary, CPR should be reinstituted after the Heimlich maneuver has been performed." [Our emphasis] At that time, AHA Guidelines were followed by the ARC and other rescue and lifeguard organizations. Did your organization follow those AHA Guidelines? In addition, the 1995 ARC manual, First Aid Fast, instructs rescuers of drowning victims, "If the airway appears clear: give 2 slow breaths. If breaths do not go in: retilt head and reattempt breaths. If breaths still do not go in: give up to 5 abdominal thrusts (Heimlich maneuver)...". Another organization that recommended using the Heimlich maneuver to save drowning victims, is the Institute of Medicine (IOM). In its 1994 report, to which you refer, the IOM concluded, "... the current ECC recommendations for establishment of the airway and ventilation should not be changed." As you know, in 1994, the ECC (Emergency Cardiac Care) recommendations included using the Heimlich maneuver to save drowning victims. You cite two episodes of vomiting following the Heimlich maneuver. CPR, on the other hand, caused vomiting and/or regurgitation in 86% of drowning victims. Manolios and Mackie (the latter is past Chairman of the World Life Saving Association Medical Advisory Committee) reported that fact in their 10-year study of drownings in Australia.

They describe vomiting as "the scourge of resuscitation". AHA Guidelines 2000 state, "The most common complication of rescue breathing is gastric inflation...Marked inflation of the stomach may promote regurgitation and reduce lung volume by elevating the diaphragm." AHA Guidelines 2000 also warn that, "Even properly performed chest compressions can cause rib fractures in adult patients....Other complications may occur despite proper CPR technique, including fracture of the sternum, separation of the ribs from the sternum, pneumothorax, hemothorax, lung contusions, lacerations of the liver and spleen, and fat emboli." Furthermore, CPR poses a disease transmission risk to rescuers. Heliobacter pylori, Mycobacterium tuberculosis, meningococcus, herpes simplex, Shigella, Streptococcus, Salmonella, and Neisseria gonorrhoeae have all infected rescuers performing CPR. AHA Guidelines reveal that " ... fears regarding disease transmission are common in the current era of universal precautions. Indeed, not only lay persons but also physicians, nurses, and even BLS instructors are reluctant to perform mouth-tomouth ventilation. The most commonly stated reason for not performing mouth-to-mouth is fear of contracting AIDS." Scientific information regarding the Heimlich maneuver for drowning is readily available. One source is my chapter "Scientific Facts Show Heimlich Maneuver Best Method for Drowning Resuscitation" in the book "DROWNING: New Perspectives on Intervention and Prevention ", published by CRC Press, under the auspices of the International Swimming Hall of Fame. This chapter, which contains 16 references, can be found on the Heimlich Institute web site, www.heimlichinstitute.org. I trust this information meets your needs.

Henry J. Heimlich, M.D. President

cc: Interested parties