Chances are, you’ve heard of the Heimlich maneuver. Since Dr.
Henry Heimlich first introduced it in 1974, the abdominal thrust
technique known as the “Heimlich maneuver” has become
part of the popular lexicon, synonymous with saving lives.
Today, it is widely recognized as part of appropriate protocol to
save choking victims.
But aquatics professionals may have been hearing about the Heimlich
in another context: drowning rescue. That’s largely thanks to
Henry Heimlich himself and one paragon of aquatics, Dr. John
Hunsucker, founder of the National Aquatic Safety Co.
Recently, Hunsucker published data claiming that his
protocols, which include the Heimlich, have shown dramatic results
in saving drowning victims.
However, medical reports supporting use of the Heimlich on drowning
victims is highly suspect. For years, a cadre of experts has
refuted Heimlich’s original claims that the technique should
be used in drowning. Today, Dr. Heimlich’s own son is perhaps
his biggest critic. Peter Heimlich, along with his wife, Karen, has
been investigating Dr. Heimlich’s work since 2002. They have
started a Website, medfraud.info, to bring to light what Peter calls his
father’s “dangerous, thoroughly discredited medical
While some might question the motivation of a son out to discredit
his father, the issue is clearly more than a family feud.
What’s more, the years of controversy between Heimlich and
the rest of the medical community — and Hunsucker’s
refusal to back down from his all-but-discredited position —
perhaps says as much about the slippery nature of studies and
research as it does about the Heimlich itself.
Here’s what is known about the Heimlich as it relates to
drowning prevention: It is not recommended by any medical authority
as a rescue technique for drowning. Furthermore, evidence suggests
that performing the Heimlich maneuver in an underwater submersion
incident actually could be harmful.
“The Heimlich is not an accepted medical practice as response
for drowning victims. Unless the medical authorities — the
Association,Red Cross — were to adopt it, I don’t see
how anyone could advocate its use,” says Gerald Dworkin, a
consultant with Lifesaving Resources Inc. in Kennebunkport, Maine.
“Dr. Henry Heimlich is the only one who has come up with
supporting studies. We should not be doing anything that’s
not approved by the medical authorities.”
Heimlich began touting the technique as a means to revive drowning
victims almost as soon as it was introduced. In a 1975 article in
the Journal of the American Medical Association, he wrote
about Victor H. Esch, MD, of Potomac, Md., claiming that Dr. Esch
watched a lifeguard rescue a nearly dead drowning victim at
Rehoboth Beach, Del., and then — somewhat miraculously
— Esch stepped in to help by applying abdominal thrusts. He
claimed to have gotten the idea after reading a recent article
about Heimlich’s new choking rescue method, which had been
introduced only three months earlier.
According to Heimlich, Esch’s actions revived the victim.
Over the next several years he published articles in several other
journals, describing at least one other case study where the victim
also reportedly was saved by the use of the Heimlich
Heimlich asserts that when people are drowning, they aspirate large
amounts of water into the lungs. He further affirms that to save
the life of a drowning victim, rescuers must clear the water from
the lungs and, simply put, the best way to do that is his abdominal
However, researchers — including Dr. Jerome Modell, a leading
drowning expert now retired — have discredited
Heimlich’s theory from the beginning.
Modell’s research, along with that of other experts,
concludes that no scientific data supports the theory that drowning
victims aspirate lots of water, which causes an obstruction in the
airway. The findings appeared in publications such as the New
England Journal of Medicine and the Journal of Emergency
Medicine throughout the last several decades.
Heimlich’s successful lobbying
Still, Heimlich apparently had some success championing his
In 1985, a committee of the American Heart Association (which included some of the
experts directly opposed to Heimlich’s theory) accepted the
use of abdominal thrusts for drowning rescues in cases where there
might be foreign objects obstructing the airways. The
recommendation, which appeared in a JAMA article the
following year, reads:
“Since the risk-benefit ratio of a subdiaphragmatic abdominal
thrust in this setting is unknown, the only time it should
definitely be used is when the rescuer suspects that foreign matter
is obstructing the airway or if the victim does not respond
appropriately to mouth-to-mouth ventilation.”
Modell affirms the decision to include the abdominal thrusts was
specifically for cases where a drowning victim may have a solid
object blocking the airway. Some might see it as a direct
concession to Heimlich.
According to some investigative reports, correspondence from that
time indicates that Heimlich operated by threatening other experts,
and accusing them of fraud. He launched a media campaign to
discredit the American Heart Association and other rescue agencies,
claiming that they made errors when CPR was adopted as a first
response in 1960.
But information uncovered by Peter Heimlich indicates that actually
it was the case studies his father used to support his position
that were at issue, and it appears fraudulent, in many
“For 30 years, my father endlessly trumpeted the cases in the
media and in medical journals as proof of his claims,” Peter
says. “I fact-checked all the cases and discovered that they
ranged from dubious to outright fraud. For example, a couple of
doctors who were the alleged rescuers in two of the ’miracle
cases’ just happened to be longtime buddies of my father, a
fact that none of them disclosed.”
One of those was Esch, according to Peter, who says he received
verbal confirmation in 2005 that Esch knew Heimlich for many years
before the time of the rescue described in JAMA. Esch died
Recent Heimlich studies
Today, Heimlich is 91 years old. Due to his advanced years,
Aquatics International did not contact him for this
article. He has never backed down from his claims. But no reputable
medical organization supports the use of abdominal thrusts as a
rescue technique for drowning.
“When you go back and look at it, there is absolutely no
science to show that it’s beneficial,” notes Dr. Peter
Wernicki, the Aquatics Sub-Council chair of the American Red Cross
Scientific Advisory Council.
The American Red Cross Advisory Council on First Aid, Aquatics,
Safety & Preparedness published a scientific review, last
updated in 2009, that recommends CPR as the first and only course
of treatment for the resuscitation of victims.
“Subdiaphragmatic abdominal thrusts are neither effective nor
safe methods for attempting water removal from the airway or lungs
of drowned persons,” the ACFASP Scientific Review
states. “No scientific literature supports the idea that
aspirated water obstructs these patients’ airways thus
hindering ventilations. Since no scientific study has shown water
can be removed from a drowned person’s airways or lungs
through subdiaphragmatic abdominal thrusts, the 2005 COSTR
Guidelines remain the CPR treatment standard for drowned
The review also points out that the use of the Heimlich actually
could be detrimental. That’s because it delays implementation
of CPR, which everyone agrees is proven effective. Plus, the
pressure on the abdomen may cause a victim to aspirate vomit into
the lungs, says Wernicki, also the medical adviser to the United States Lifesaving
Association, and a member and past chair of the International
Lifesaving Federation Medical Committee.
“Any attempt to remove the water from the airway is
unnecessary, will delay CPR, hamper the correction of a drowned
person’s hypoxemia [extremely low blood oxygen pressure], can
induce vomiting, and may cause visceral or vascular injuries to the
drowned person,” reads the ACFASP statement.
The statement cites research published in JAMA by Dr.
James Orlowski which describes a case study of a 10-year-old boy
who was given the Heimlich maneuver after being submerged. The
child vomited, which damaged his lungs and hindered rescuers’
efforts to perform CPR. The boy later died.
Orlowski notes that the Institute of Medicine also came to the same
conclusion that the American Red Cross did.Jeff Ellis & Associates
Inc. of Ocoee, Fla., which did include the Heimlich maneuver in
its protocols starting in 1995, now follows the medical agencies.
It dropped the use of the Heimlich in 2000.
Still, in 2010 Hunsucker published a report in the
International Journal of Aquatic Research and Education,
which explains NASCO’s position. He followed that report last
year with a public statement. But medical experts and reports in
the popular media have continued to question NASCO’s
NASCO was founded in 1974, and the current protocol has been in
place since the mid- to late 1990s, according to the 2010 IJARE
report that Hunsucker co-authored with Scott Davison, vice
president of development at NASCO. Hunsucker holds Ph.D.s in
mathematics and engineering.
NASCO’s protocol has six major parts: scanning, victim
identification, moving to the victim, in-water intervention
(IWI)/removing the victim from the water, out-of water intervention
(including CPR), and management, as described in the paper. The
Heimlich maneuver comes in as an in-water intervention technique,
defined in the paper as “applying a resuscitation procedure
in the water, immediately after contacting a drowning
victim.” The company advocates the use of five (and only
five) abdominal thrusts in cases of short-duration submersion (one
minute or less), while the victim is still in the water. That
procedure should be followed immediately by extricating the victim
from the water and performing CPR according to American Heart
“These thrusts delay extrication between four to six
seconds,” NASCO stated in the open letter on the subject,
dated Oct. 30, 2011. “The intent of these thrusts is to begin
to initiate respiration.”
To define the effectiveness of NASCO’s use of the technique,
Hunsucker and Davison’s IJARE report analyzed data from
waterpark client rescue reports dated between 1999 and 2009. These
included 56,000 rescues and 32 respiratory failures resulting in
Those findings show that the NASCO protocols including the use of
abdominal thrusts resulted in restored spontaneous respiration in
approximately 87 percent (28) of respiratory failure victims.
Spontaneous respiration was restored using just IWI in 14 (nearly
44 percent) of the 32 respiratory failure cases, and abdominal
thrusts done out of the water restored spontaneous respiration on
two other cases.
The ongoing dispute
NASCO has received a significant amount of criticism for its
In 2009, three fatal drownings at NASCO facilities raised the issue
of NASCO’s use of the Heimlich in the popular media. Last
year, the Northern Virginia Park Authority eliminated the use of
the Heimlich in its lifeguard rescue protocols after a story in the
Washington Post made the general public aware that the technique
had been discredited by the medical community as an acceptable
protocol for drowning resuscitation.
“All of us in the emergency medical field — whether
first responder, EMT, paramedic, whatever — are not the ones
who set the protocols. The protocols are set by medical experts,
and it’s our job to follow those protocols. Period,”
says B. Chris Brewster, president of USLA. “If, for example,
a paramedic is involved in some sort of emergency intervention and
takes actions that are inconsistent with the protocols, it’s
a major violation of professional ethics.”
The question of ethics was raised by respected experts, including
Wernicki, Peter Chambers, Roy Fielding, Terri Lees, David
Markenson, Francesco Pia and Linda Quan, in rebuttal to
NASCO’s IJARE article. The rebuttal, published in IJARE in
2011 stated that “the study failed to adhere to all three
recognized principles of human subject research — autonomy,
beneficence, and justice. …”
“The study was ill-conceived and poorly carried out,”
Wernicki summarizes. “The purported outcomes do not support
the conclusions stated. The review of the literature is incorrect
and misleading. It unethically subjected thousands of children and
adults to a universally condemned procedure. It had no oversight or
approval by any scientific board. It was performed on unsuspecting
subjects who never gave informed consent. The study authors had
significant conflicts of interest and potentials for
For his part, Hunsucker continues to maintain the position that
abdominal thrusts work as an in-water intervention technique that
is a small part of the overall NASCO response protocol. He points
out that NASCO’s drowning rate of 0.00635 per 100,000
compares favorably with the CDC estimate for all pool drownings of
0.6 per 100,000.
He answered the questions over ethics in a response to the rebuttal
article, noting, “This was particularly interesting since one
of us teaches professional ethics at the university.”
In a letter to Aquatics International, he also notes that
“most other major organizations have not made any significant
improvements in their protocols associated with drowning since the
inception of CPR in the middle ’70s.”
While it’s case closed on the Heimlich maneuver for most, few
are likely to deny that continued drowning research and review,
appropriately conducted, can only help to save lives. For now, that
is perhaps the one point of common ground.
As Hunsucker wrote to Aquatics International, “It is time to
move forward and find even better methodologies to deal with the
tragedy of drowning.”