my father's bizarre 1985 correspondence with american heart association committee chair joe ornato...

8/9/2019 My father's bizarre 1985 correspondence with American Heart Association committee chair Joe Ornato MD

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VIERUNIVERSITY Henry J. Heimlich, M.D.

Profes sor of Advanced Clinical Scien ces

August 19, 1985

Joseph P. Ornato, M.D.Medical College of VirginiaVirginia Commonwealth UniversityP.O. Box 525Richmond, VA 23298-0001

Dear Dr. Ornato:

On J ul y 11- 13, 1985, t he Ameri can Red Cross/ Ameri can Hear t Associ ati on met i nDal l as and establ i shed standards for f i rst ai d i nst ruct i ons. On J ul y 13, aschai rman of t he panel on drowni ng, you reported t he f i ndi ngs of your panel t othe 350 conf erence par t i ci pant s, and on J ul y 22, submi t ted a wr i t ten r eport toyour panel members. I n both i nst ances, your report stated that your panel recommended the Hei ml i ch Maneuver f or t reatment of drowni ng. I nexpl i cabl y, yourl ast wr i t t en report to your panel member s, dated August 5, 1985, i gnores yourprevi ous reports and el i mi nates the Hei ml i ch Maneuver , cont rary t o the sci ent i f i c f acts and concl usi ons presented at the open meet i ng of your panel i nDal l as.

I t i s apparent that Red Cross f i rst ai d i nst ruct i ons are based on di scussi onsand deci si ons that are not subj ect to the scruti ny of the sci ent i f i c communi tyor the publ i c. What occurred between your wr i t t en report of J ul y 22, 1985 *>?that of August 5, 1985, t hat caused you to total l y negate the f i ndi ngs of tconf erence? '

A si mi l ar act i on was reveal ed at the same 1985 Dal l as conf erence, regardi ngt reatment of choki ng. Dr . J ude, a l ong ti me advi sor t o the Red Cr oss, desc ;bed how such a nonsci ent i f i c deci si on l ed to ah i ncorrect dangerous r eccmmert i on. He stated that at a si mi l ar Red Cross sponsored conf erence near l y teyears ago the commi t tee knew that the Hei ml i ch Maneuver was the best t reats -f or choki ng and they had no evi dence that backsl aps had any val ue* Dr . J uc ,t hen sai d t hat the commi t tee members debated t he use of the name Hei ml i ch ?euver unt i l 2: 00 A. M. , rather than consi der i ng the sci ent i f i c f acts. ( App IAs a r esul t , backsl aps were taught by the Red Cross as the pr i mary f i rst af or choki ng f or ten years and deaths f ol l owi ng backsl aps were reported i n rcal j ournal s dur i ng that per i od,

The above statements and al l i nf ormati on that f ol l ows are documented i n th

t ranscri pt s of the of f i ci al tapes of the 1985 Red Cross conf erence and i nten st at ement s:

3800 Victory ParkwayCincinnati, Ohio 45207-1096

513/53,1-1053

| N * * * * *


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1. On July 12, 1985, your panel on drowning met in open session and recom

mended that the Heimlich Maneuver be included as a treatment for drown

ing. The only point of contention was whether the Heimlich Maneuver

should precede or follow rescue breathing.(App II)

2. On July 13, 1985, chairpersons reported the recommendations of their

panels to the 350 conference participants. You reported that your panel on drowning recommended that when mouth-to-mouth resuscitation was

unsuccessful in treating drowning, the Heimlich Maneuver should be

used. You presented only one side of the panel recommendations, but

unequivocally included the Heimlich Maneuver.(App III)

3. Your written draft to the panel members of July 22, 1985, also recom

mends performing the Heimlich Maneuver for drowning.(App IV) My letter

of July 30, 1985, clarified your ommissions and changes.(App V)

4. On August 5, 1985, your last draft to the panel eliminated the HeimlichManeuver as a treatment for drowning. This action totally disregarded

recommendations 'of your panel, ignored your report to the conferenceand countermanded your original written draft to panel menbers.(App VI)

In your August 5th report, the reasons you stated for eliminating the Heimlich

Maneuver were the same ones presented by Dr. ModelIat the open panel meetingof July 12th. They were discarded by the panel, being contrary to scientific

fact and not in keeping with Dr. Modell's own published studies. The reasons

for not using the Heimlich Maneuver in drowning that you stated in your August

5th report and the actual facts are as follows:

1. Your report of August 5, 1985, states "the need for clearing the air

way of aspirated water has not been proven scientifically...". That'

is not true. Edward A. Patrick, M.D, Ph.D., professor of Engineering

a Computer Sciences, University of Cincinnati, published a scientific

paper proving that the Heimlich Maneuver expels water from the lungs

and successfully resuscitated a drowning person after mouth-to-mouth

had failed.(App VII) My scientific paper published in the Annals of

Emergency Medicine includes similar documented reports by trained EMT's

and a definitive report from Dr. Victor Esch, Chief Fire Surgeon of

Washington DC and an advisor to the Red Cross on water safety.(App

VIII) Both of these papers were described and referenced at your

panel meeting. Dr. Patrick was present at the time.

2. Your August 5th report ambiguously states that "ModelI found at most

only a modest amouht of water is aspirated by drowning victims and that

the water is rapidly absorbed from the lungs into the circulation ...".

(App VI) Your statement is inaccurate and incomplete. Dr. Modell's

presentation at your panel and his scientific publications prove that

90%of drowning victims have water in the lungs,, and 85% of them aspir

ate up to 10cc of water per pound of body weight. The remaining 15%,

he stated, aspirate more water than that. In other words, a 1001b per

son aspirates up to 1000cc (more than a quart) of water, which is the

cause of deaths from drowning.(App VIII)

Dr. Modell further showed that sea water remains in the lungs and draws

additional fluid from the blood, a fact you heard stated at your panel


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meeting and omitted entirely in your report. Dr. Modell claimed that

only fresh water is absorbed from the lungs into the blood stream.(App

VIII) At your panel meeting, it was pointed out that as fresh water

is absorbed from the lungs while the victim is in the water, more water

replaces it in the lungs and, with cardiac arrest, no water can be ab

sorbed even when the drowning victim is brought onto the land. At the

conference, the frequent presence of mud in the lungs of drowning vic

tims was also discussed. Mud can only enter the lungs with aspirated

water. Furthermore, the opening paragraph of your August 5th report

describes the situation that occurs in drowning including "terminal

gasping with flooding of the lungs..."i(App VI)

Your August 5th report also states that "most authorities...feel that an at

tempt to remove water from the breathing passages is unnecessary and potential

ly dangerous because it could eject gastric contents and cause aspiration."

(App VI) Facts presented at your panel meeting on July 12th revealed thefal

lacy of that statement as follows:

A. Such aspiration has not occurred in any drowning person who was saved

by the Heimlich Maneuver even after mouth to mouth failed. (App VIII)

B. The drowning person is treated because he is not breathing and,, therefore,cannot inhale water.

C. Oxygen can not get into the blood until you get the water out of the

lungs.

D. Your recommendation of August 5 condemns the drowning person to die

due to water in the lungs rather than performing the Heimlich Maneuver

to expel water. Your sole reason is that Dr. Modell speculates that'

the victim may aspirate some water. Yet that might only occur when,

as a result of the Heimlich Maneuver expelling water, the victim re

covers and starts breathing.(App VIII)

For more than 30 years, until 1960, the Red Cross taught the Schafer Prone

Pressure rescue method for the treatment of drowning, pressure on the Lower

back which intermittently elevates the diaphragm, as occurs with the Heimlich

Maneuver. It was affirmed that the procedure expelled water from the lungs. -

More than 20 years ago, the Red Cross introduced mouth-to-mouth resuscitation

as the primary treatment for drowning. Those responsible for that decision

forgot that earlier manual methods expelled water by elevating the diaphragm

and compressing the lungs. They did not appreciate that mouth-to-mouth is in

effective in the presence of aspirated water. In the subsequent'20 years,

drowning deaths increased annually in the United States and exceed8,000peryear.(App VIII) Parties responsible for that decision are still in dominant

positions in the Red Cross.

Prior to July 13, 1985, the use of mouth-to-mouth as the primary treatment for

drowning can be considered a scientific'error. In view of the decision of your

panel at the 1985 Red Cross conference to include the Heimlich Maneuver as a

treatment for drowning since it expels water from the lungs, a deliberate at

tempt to exclude the Maneuver subsequent to that date must be regarded with

suspicion.


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Other actions of the Red Cross since the Dallas meeting are also subject toquestion. You are undoubtedly aware that at the panel on choking at the 1985Dallas meeting physicians and scientists presented published data and emphasiz-ed that backslaps drive an object in the throat tighter into the airway causingdeaths. Reports in the medical literature for the past 130 years were cited

confirming that fact. That is why, after teaching backslaps as the primarytreatment of choking for ten years, the conference concluded that backslapswere to be eliminated from Red Cross first aid training and posters. Chestthrusts, taught by the Red Cross for ten years, were also discarded due to in-juries and deaths caused by crushed chests as evidenced with cardiopulmonaryresuscitation (CPR). The press statement issued by the Red Cross, however,stated:

"Barker (Dr. Lewellys F. Barker, Senior Vice President of the Red Crossand CPR Director) emphasized that the Red Cross still does not believeback blows to be unsafe. 'We think the abdominal thrust has something ofan edge,' he said. 'It is at Least as good, very probably better. But wedon't" see great urgency or emergency in making the change. We don't think

there is tremendous public health risk in using what people have beentaught in the past.'" (Los Angeles Times, July 23, 1985)

Millions of Americans taught by the Red Cross have, therefore, not been warnedthat their actions in treating a choking victim, back blows and chest thrusts,can be lethal,, Advising them of that fact is a national public health emergen-cy. The same situation is true regarding the treatment of a drowning victim.The medical profession, scientific community, public health authorities,, andthe public must now be informed of this.

Decisions resulting from faulty research are life threatening and can not beconcealed. Your obligation, Dr. Ornato, is not only to the Red Cross and Heart

Association, but your actions reflect on the Medical College of Virginia of theVirginia Commonwealth University. No more lives must be lost.

HJH/jh

Enclosurescc: President, American Red Cross President, American Heart Assn,

President, Am. College of Cardiology Director, Heart, Lung 8 Blood Inst.Dean, Medical College of Virginia Interested partiesPresident, VA Commonwealth Univ.


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Medical College of Virginia

Virginia Commonwealth University

August 23, 1985

Henr y J . Hei ml i ch, MDProf essor of Advanced St udi esXavi er Uni ver si t y3800 Vi ct ory Par kwayCi nci nnat i , Ohi o 45207- 1096

Dear Dr . Hei ml i ch:

I r egr et t hat you have mi sunderst ood t he pr ocess f or r evi si on of t he "St andards and Gui del i nes f or Cardi opul monar y Resusci t at i on and Emergency Cardi ac Car e" . The meet i ng r ecommendat i ons ser ve as an i mpor t ant , but not excl usi ve, sour ce ofi nput f or t he devel opment of t he new CPR St andar ds and Gui del i nes . The act ual wr i t i ng of t he new St andar ds i s ul t i mat el y t her esponsi bi l i t y of t he Conf er ence St eer i ng Commi t t ee. The dr af tdocument i ni t i at ed f rom our panel i s t he f i r st of sever al addi t i onal st ages of wr i t i ng, di scussi on, and peer r evi ew.

Much di scussi on, i nput , and r evi ew has occur r ed si nce t he'Speci al Si t uat i ons panel . As chai r man of t hat panel , I have

sol i ci t ed addi t i onal i nput f rom you, ot her member s of t he panel ,and ot her not ed exper t s i n t hi s f i el d. I have shared each of t heworki ng dr af t s wi t h you. The l at est dr af t document i s a consensus st at ement of t he panel . At t hi s poi nt , you ar e t he onl ymember of t he panel who obj ect s t o any por t i on of t he draf tdocument . I must emphasi ze that t he draf t document does not ;r ef l ect my per sonal opi ni on but r at her t hat of t he gr oup. I haveser ved as a neut r al aut hor expr essi ng t he maj or i t y consensusopi ni on, poi nt i ng out ar eas wher e sci ent i f i c pr oof i s l acki ng andf ur t her r esear ch i s needed.

Al t hough your opi ni on about t he need f or your maneuver i ncases of near - dr owni ng i s i mpor t ant and respect ed, i n t he opi ni on

of t he ot her panel i st s t her e i s not yet adequat e sci ent i f i c pr ooft hat i t i s necessar y, saf e, or ef f ect i ve. Your 1981 ar t i cl e i nt he Annal s of Emergency Medi ci ne does not cont ai n any sci ent i f i cdat a f r om ani mal or human r esear ch. You negl ect ed to f orward t het wo st r ong l et t er s of di ssent publ i shed i n the Annal s of Emer gency Medi ci ne rel at i ng to your publ i cat i on ( encl osed) .

Section of Emergency Medical ServiceB P.O. Box 525 Richmond, Virginia 23298-0001


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The onl y human data your 1981 ar t i cl e r ef er s t o i s Dr .Pat r i ck' s case r epor t of t he t wo- year ol d near dr owni ng vi ct i m,publ i shed i n a non- peer r evi ew t r ade j our nal . I n t he opi ni on oft he gr oup, t hi s non- r ef er eed case r epor t r ai ses mor e quest i ons

t han i t answer s. Dr . Pat r i ck stat es that he i nt ubat ed t he chi l dand heard no br eat h sounds. Water was ej ect ed f r om t he t ube f ol l owi ng a Hei ml i ch maneuver and:

"af t er at t achi ng the bag wi t h oxygen to t he endot r achealt ube, l oud ai r f l ow sounds- wer e heard over t he l ef t l ung,whi l e f ai nt ai r f l ow sounds wer e heard over t he r i ght l ung.A subsequent xray showed the st omach and i nt est i nes ext ensi vel y di l at ed wi t h gas. "

An al t er nat e expl anat i on of t hese obser vat i ons i s t hat Dr . Pat r i ck i nadver t ent l y i nser t ed t he endot r acheal t ube i n t he esophagus and di dn' t r ecogni ze i t . Gi vi ng hi m t he benef i t of t he

doubt , even i f t hi s case r epor t does repr esent a successf ul useof t he Hei ml i ch maneuver i t i s t he onl y such evi dence anywhere i nthe l i t er at ur e.

I t i s ei nci dent s pehundreds ofmout h r escuevi ct i m. Youpermi t t he ubr eat hi ng, bpanel membersent i ng the

maneuver unlobst r uct i onr at i on of gaf r equent l y evi ct i m wi thquent l y i n tswal l ow l argt he st omachmaneuver was

st i matedr year wit housandsbr eat hi nar e aski

se of youased on vs, Dr s. AU' ni ted St

ess t herebecause ostr i c conj ect i on oyour manehe choki ne quant i twi t h your

abandone

t hat t her e ath 8, 000 fa tof l i ves ha

g as i ni t i alng t hat t her maneuver fery l i t t l e sI an St ei nmanates Coast G

i s evi dencef t he r i sk otents. Therf gast r i c couver . Al t hog vi ct i m, dri es of wat ermaneuver .

d by t he Red

re over 80, 000al i t i es. For tve been saved u

t r eat ment of tSt andards r ecomi r s t , i n pl aceci ent i f i c evi deand Mar t i n Nem

uar d, obj ect to

of- ( non- wat er )f i nduci ng vomie i s as yet nont ent s occur s iugh vomi t i ng maowni ng vi ct i mswhi ch mi ght be

The breaki ng ( jCr oss because

near - dr owni nghe l ast 25 year s,si ng mout h- t o-he near - dr owni ngmend or at l eastof r escuenee. Two of t hei rof f r epre-

t he use of your

f orei gn bodyt i ng and aspi -dat a on hown the drowni ngy occur i nf r e-i nvol unt ar i l yej ect ed f rom

ackkni f i ng)of t hi s probl em. .

As your vi ews r ef l ect an i mpor t ant ( al bei t mi nor i t y) opi ni on, I have f orwarded your memorandum of J ul y 30, 1985 and yourl et t er of August 19, 1985 to Dr . Rami r o Al bar r an- Sot el o. He i s

i n char ge of t he next st ep i n t he revi ew and wr i t i ng pr ocess oft hi s sect i on. I have al so sent a copy of your cor r espondence toDr . Bi l l Mont gomery, t he chai r man of t he St andards Conf erence,who wi l l shar e i t wi t h the St eer i ng Commi t t ee.

Fi nal l y, I must comment on t he manner i n whi ch you haver el at ed to me and the Nat i onal St andar ds pr ocess. I r ecal l t hatt he ni ght bef or e the Speci al Si t uat i ons panel i n Dal l as youwar ned me t hat i f t he St andards were not wr i t t en to your sat i sf act i on, you i nt ended to "go to t he medi a". I r emember r e-


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spondi ng t o your st at ement by sayi ng t hat we each must do whatour j udgement and consci ence di ct at es, but t hat I wi shed f or youto under st and t hat I woul d not al l ow such consi der at i ons t o

i nf l uence t he f ai r and i mpar t i al manner i n whi ch the panel woul ddeal wi t h t he sci ent i f i c i ssues.

I am f r ankl y angry t hat you have chosen to send a copy ofyour August 19 l et t er t o' t he i mpor t ant , of f i ci al s l i st ed at t hebot t om of . your l et t er , most of whom have had not hi ng her et of or eto do wi t h the Nat i onal St andar ds process or t he i ssue. Such anact i on suggest s t o me that you ar e seeki ng t o appl y l ever age to.me per sonal l y or t he commi t t ee to yi el d to your bel i ef s. I t i s ashame you cannot under st and t hat al l t he St andards r equi r e i ssci ent i f i c evi dence t hat t he use of your maneuver i s necessar y,saf e, and ef f ect i ve.

We al l shar e a genui ne i nt er est i n i nvest i gat i ng your i deasf ur t her . As a r esul t of t hi s debat e one commi t t ee member i sdesi gni ng a st udy t o i nvest i gat e t he ef f i cacy of your maneuver -i nt he near - dr owni ng dog model . I f you are aware of any human orl abor at or y ani mal dat a publ i shed i n a peer - r evi ew sci ent i f i c.j our nal whi ch support s your bel i ef s, I urge you to share i t wi t hme and I wi l l f or war d i t t o t he appr opr i at e i ndi vi dual s deal i ngwi t h t hi s sect i on of t he St andar ds i n t he upcomi ng mont hs.

Ver y t r ul y your s,

**lb

J oseph P. Or nat o, MD, FACCAssoci at e Pr of essor of I nt er nal Medi ci ne ( Car di ol ogy)

cc: Dr . Bi l l Mont gomer yDr . Rami r o Al bar r an- Sot el oSpeci al Si t uat i ons panel member sPr esi dent , Amer i can Red Cr ossPr esi dent , Amer i can Col l ege of Car di ol ogyDean, Medi cal Col l ege of . Vi rgi ni aPr esi dent , Vi r gi ni a Commonweal t h Uni ver si t yPr esi dent , Amer i can Hear t Associ at i onDi r ect or , Hear t , Lung & Bl ood I nst i t ut e


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WIEK-UNIVERSITY

o

1

Henry' J. Heimlich, M.D.Profess or of Advanced Clinical Sciences

*&

September 24, 1985

Joseph P. Ornato, M.D.Medical College of Virginia

Virginia Commonwealth UniversityP.O. Box 525Richmond, VA 23298-0001

Dear Dr . Ornato:

I am respondi ng to your l et ter of August 23, 1985, concerni ng your acti vi t i esas chai rman ofa panel t o updat e t he t reatment of drowni ng, at t he Conf erencei n Dal l as, July 11-13, 1985, cosponsored by t he Ameri can Red Cr oss.

As Chai rman of t he panel on drowni ng, i t i s your responsi bi l i t y to t ransmi t therecommendat i ons and conclusi on?-, of your panel to t he Conf erence Steeri ng' Com-rdttt-e. Based on your report , that Commi t tee der i ves Standards and Gui del i nesfor t he t reat ment of crovn. i ng to be taught by the Red Cross and Ameri can Hear tAssoci at i on f or t he. next f i ve years, Subsequent to the Conf erence, you reversed your panel ' s recommendat i ons and wi thhel d t hei r concl usi ons i n your repor tto the Conf erence Steeri ng Commi t t ee. Shoul d your act i on go unchal l enged, exi st i ng er rors i n Red Cross i nst ruct i ons wi l l not be di scl osed or corrected andvitii .eo'frssary drowni ng deaths wi l l cont i nue t o occur .

Al l f acts i n thi s l et t er , whi ch ci t es changes and omi ssi ons i n your report tothe Conf erence Steeri ng Commi t t ee, are documented i n the of f i ci al Conf erencet apes, publ i shed i n sci ent i f i c j our nal s, or are avai l abl e i n your wr i t t en r epor t s t o your panel and st atement s i n your l et t er of August 23.

CONCLUSI ONS I K THE FOLLOWI NG HANKER;MKI TI Si YOU ALTERED YOUR PANEL' S

You wi thhel d f rom the Conf erence Steer i na Commi t tee. the recommendati on ofyour panel .

On J ul y 12, 1985, i n the presence of a l arge audi ence of Conf erence par t i

ci pants, t he panel that you chai red made the f ol l owi ng recommendati on af terdi scussi on of sci ent i f i c evi dence: I n t he drowni ng person, t he rescuer;.;h'. ...Idf i r st per f orm mouth- to- mouth breathi ng and, i f t he vi ct i m "does notrespond promptl y", then the Hei ml i ch Maneuver shoul d be perf ormed.

Your panel ' s recommendati on to use the Hei ml i ch Maneuver f or drowni ng came

3800 Vi ctory' Par kwayCi nci nnat i , Ohi o 45207-1095

513/ 531-1053


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Joseph P. Or nat o, H.D.September 20. 1985Page 2

about in the following manner: Your panel consisted of three participants Dr. Modell, Dr. Steinman and myself and one nonparticipating RedCross observer. Dr. Modell, in his presentation, initially advised againstusing the Heimlich Maneuver in drowning stating that it might cause aspiration of gastric contents. I presented the scientific evidence for use ofthe Heimlich Maneuver and why such aspiration was not of concern. Dr.

Modell then stated: "I would recommend that in the near-drowned victim thatmouth-to-mouth be done first and if the patient does not respond promptly,then the, let me call it the abdominal thrust as described by Heimlich,then there will be no question about it." I agreed, but recommended thatthose who believe it is important to first expel water from the lungs be

permitted to use the Heimlich Maneuver as the initial procedure.

Dr.Modell then said: "Well, that I will leave up to our chairman and hiscommittee. I think they've heard what we've had.to say and I think it istrue that we don't violently disagree. We may disagree on methodology, orwhether the chicken came first or the egg came first, and which is the

proper one to comefirst, and hopefully, Joe(Ornato),you have some direction for that."

July 13, 1985, af t er meet i ngin private with your Committee the ni ght before,you repor t edto the 350conference participants that your panel concl uded t hat t he Hei ml i ch Maneuver shoul d be used i n drowni ng persons whenm.outh-fco-i ri otttb does not achi eve adequate vent i l at i on,

Fur t her mor e, subsequent to the Conf er ence, your f i rst wr i t t en r epor t to----- your panel , J ul y 22, 1985, reaf f i rmed t he recommendat i on that the Hei ml i ch

Maneuver be used f or the treatment f or drowni ng when mouth- t o-mout h docsnot achi eve adequate vent i l at i on. (App I )

l !LJ HLXgP-g.C. t. .. tl f. .Au ' ' - ,' st 19, 1985, to t he Conf erence Steer i ng Commi t t ee,

you t otal l y or: : i tted your _panel |_s recommendat on that t he Hei ml i ch Maneuverbe used when mouth- to- mouth f ai l s. I nstead your repor t advi ses agai nstuse of t he Hei ml i ch Maneuver , even i n drowni ng vi ct i ms who do not respondto mouth-to-mouth and are, therefore, condemned to die. (App II) In yourl et t er to me of August 23, a copy of whi ch you sent to the Conf erenceSt eer i ng Commi t t ee, you do not ment i on your panel ' s recommendati on that t heHei ml i ch Maneuver be used f ol l owi ng mont h- t o- mout h f ai l ure. You obscuredthat f act by r eferr i ng onl y t o my r ecommendati on t hat the Hei ml i ch Maneuverbe permi t t ed t o be used f i r st .

2. You wi t hhel d f rom the Conf erence St eeri ng Commi t tee the sci ent i f i c evi dencei ndi cat i ng t hat a l arge amount of wat er i s aspi rated by drowni ng persons,t hus conceal i ng t he need to expel water f rom the l ungs by means of t heHei ml i ch Maneuver .

Your ori gi nal draft report of J ul y 22, 1985, to your panel , bassd on thesci ent i f i c evi dence presented at your panel ' s open sessi on, descr i bes the"f l oodi ng of t he l ungs" that occurs i n drowni ng and states "aspi rat i on ofa moderate amount of water (up to 22 ml / kg body wei ght ) occurs i n 80- 90percent of crowni ngs". (App I ) That f i gure, based on Dr . Model l ' s publ i shed st udi es, means that a 100 l b drowni ng person aspi rat es up to 1000cc of wat er .

Your report to. hej Cj onf ere nee Steer i ng Commi t t ee of Au gust 19, 1985, does


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J oseph P. Or nat o, M. D.September 20. 1985Page 3

not repor t t he above f i gures and merel y st at es; "Model l ( 2- 3) f ound t hatat most onl y a modest amount of wat er i s aspi rated. . . ". (App I I ) Thusyour repor t conceal s the evi dence t hat a l arge vol ume of water i s aspi r ated by a drowni ng person.

Another omi ssi on f rom your Conf erence Steer i ng Commi t t ee repor t of August

19 further serves t o di st ract at t ent i on f rom the l arge vol ume of aspi ratedwater i n t he ai rway of drowni ng vi ct i ms. Your report st ates that Model lf ound that "f resh water i s rapi dl y absorbed f rom the l ungs i nto the ci r cul at i on". (App I I ) You omi t ted the remai nder of Dr . Model l ' s f i ndi ng, namel y, t hat sea water (sal t wat er ) i s not absorbed f rom the l ungs but drawsaddi t i onal wat er i nto the l ungs f rom t he ci rcul at i on. I n addi t i on, you di dnot ment i on t he fol l owi ng f acts presented at your panel meet i ng: Whenf resh water i s absorbed f rom the l ungs of a person who i s drowni ng, i t "i srepl aced i n t he l ungs by mor e water . Af t er cardi ac arr est occur s, no addi t i onal water can be absorbed.

I n your repor t to the Conf erence Steer i ng Commi t tee, August 19, 1985, af tercl ai mi ng t hat "At most onl y a modest amount of water i s aspi rated", youil.l-r.Et~that "most author i t i es" f eel t hat wat er need not be expel l ed f romthel ungs of a drowni ng person. (App I I ) Who are the "most author i t i es" whoseopi ni on caused you to reverse your panel ' s recommendati on to expel waterf rom the l ungs by means of the Hei ml i ch Maneuver?

Revi ewi ng your t hree draf t r eport s to your panel i n sequence reveal s t hemanner i n v/hi ch you gradual l y r emoved your panel ' s r ecommendat i ons and concl usi ons f rom your repor t to the Conf erence Steer i ng Commi t t ee.

Prof essor Pat r i ck proved that t he Hei ml i ch Maneuver expel s water f romt hel ungs cf a drown"ne, vi ct i m. I n your l et t er of August 23? you at tempt t odi i --*-' t ' ' ^'Joj f al sel y accusi ng hi m of i ntuba' ci ng the pat i ent ' se

Lc

2 L1_i L 1 _ t a) the t rachea.

Prof essor Edward Pat r i ck, M. D. , Ph. D. , publ i shed a sci ent i f i c paper provi ngthat t he Hei ml i ch Maneuver expel l ed wat er f rom the l ungs. Use of the Maneuver saved t he l i f e of a drowni ng two year ol d after mouth- - to-mouth andmechani cal ai r i nsuf f l at i on ut i l i zed f or over a hal f an hour had f ai l ed torev-; .ye t he 5nf art . To you?" l et t er of August 23, 1983, to vae. ;ln an at t emptto di smi ss t hat sci ent i f i c evi dence, you accuse Dr . Pat r i ck of mal f easance,specul at i ng t hat he "i nadver tent l y i nserted an endot racheal tube i n t heesophagus and di dn' t recogni ze i t " . Dr . Pat r i ck, i n hi s l et ter of September &, 1985, to you, responds wi th the radi ol ogi cal proof t hat the endot racheal t ube was i n the t rachea.

Unabl e to chal l enge Prof essor Pat r i ck' s sci ent i f i c f acts, you further seekto demean hi s work by sayi ng hi s art i cl e di d not undergo peer revi ew, Dr .Pat r i ck, whose sci ent i f i c t extbooks are publ i shed throughout cue wel d, i nhi s l ett er of September 4 to you, names t he professor who conf i rmed the accuracy of hi s f i ndi ngs t hrough peer r evi ew. Once agai n, i t was proved thatthe Hei ml i ch Maneuver expel l ed the wat er f rom the l ungs. (App I I I ) Haveyou not i f i ed t he Conf erence Steeri ng Commi t tee that you were i n error andthat t he sci ent i f i c evi dence shows t hat your panel ' s r ecommendat i on t o uset he Hei ml i ch Maneuver i n drowni ng was correct?

Ycu att r i but e your charges agai nst Dr . Pat r i ck to "the opi ni on of the


11/24

Joseph P. Ornato, M.D.Sept ember 20. 1985Page 4

group". Who are the members of "the group"? Anonymity is not acceptablefor scientists considering life and death data. In the same letter of August 23, you advise that it is the intention of "one committee member" ofyour panel to repeat tests of the Heimlich Maneuver in animals, even thoughthe success of the Maneuver in drowning has already been established for

humans. Since there were only three of us, it must be either Dr. Steinmanor Dr. Modell. It seems unlikely that Dr. Steinman has an animal laboratoryat his Coast Guard station. Dr. Modell has an animal laboratory. But atyour open panel meeting on July 12, 1985 at the Dallas Conference, the official tapes show that after the scientific evidence was presented anddiscussed, including the volume of water in the lungs of a drowning victim andthe possibility of aspiration of gastric contents, Dr. Modell was the first

member of your panel to recommend that the Heimlich Maneuver be used totreat drowning victims. At that time, he also advised you to transmit thatrecommendation to the Conference Steering Committee. Who is the namelesscommittee member, Dr. Ornato, who would now embark on such an animal studythat would only serve to delay exposure andcorrection of present errors i nRed Cross instructions for the t reatment of drowni ng andresult in further

l ossof life?

In addition, you state that Dr. Pat r i ck' s case report i s"the only (youremphasi s) such evidence anywhere in t he l i t erat ure" of a successf ul use ofthe Hei ml i ch Maneuver f or drowni ng. That i s not true, - Al t hough t he sci ent i f i c document at i on i n that case al one provi des wi th cer tai nt y t he evi dencethst t he Hei ml i ch Maneuver expel s water frcr.i t he l ungs, you wi l l f i nd sedi t i on al cases reported i n the J ournal of the Ameri can_Met i i cal Associ at i on

JiAi l -A-t anc' ether j ournal s. These ar t i cl es document case repor t s i n whi chmouth- t o- mout h resusci t at i on f ai l ed; the drowni ng person recovered af tertheHeimlich Maneuver expelled water f romt he l ungs. Those cases were al soreported at your panel meet i ng.

Al ong wi th your l et ter of August 23, you di ssemi nated two l et t ers publ i shedrel at i ve tomy 1981 article in the Annal s of Emergency Medi ci ne. I n yourl ett er , once agai n, you avoi ded any ment i on of the sci ent i f i c evi dence i nthe ar t i cl e, cl ai mi ng, wi t hout any basi s, that the ar t i cl e cont ai ned nosci ent i f i c data f rom ani mal or human research. You i gnore t he 24 ref er ences ci ted i n t hearticle as di d t he other t wo l et ter wr i t ers, who were;o advi sed i n my publ i shed r esponse whi ch you al so possess. Those 24 r ef erences provi de sci ent i f i c evi dence that subdi aphragmat i c pr essure, as i nthe Hei ml i ch Maneuver , expel s water f rom the l ungs of drowni ng persons.

** I n your report t o the Conf erence Steer i ng Commi t tee, of August 19 and i nyour l et ter of August 23, you advi se agai nst usi ng t he Hei ml i ch Maneuver to

save a drowni ng vi ct i m, specul at i ng t hat i t may cause aspi rat i on of gast r i ccont ent s. Your panel , i n i t s open sessi on on__J ul y 22, di scarded t hat sup-VJt?-yc. n_XcI " t he f ol l owi ng reason:

Even assumi ng t hat t he vi cti m may aspi rat e, an unl i kel y possi bi l i t y, yourpanel recommended that the Hei ml i ch Maneuver shoul d be used af ter mouth- t o-mouth has f ai l ed, rather than l et t i ng the drowni ng person di e. When theHei ml i ch Maneuver saves a drowni ng vi cti m af ter mout h- t o- mout h f ai l s, t hepossi bi l i t y of t he recovered person aspi rat i ng i s of l i t t l e consequencecompared t o comdemni ng hi m to di e. You present no sci ent i f i c evi dence f orreversi ng your panel ' s acti on i n that regard.


12/24

J oseph P. Or nat o, H. D.September 20. 1985Page 5

You al so i ncl ude i n your repor t to the Conf erence Steer i ng Commi t tee a total l y unrel ated procedure, j ackkni f i ng the vi ct i m, as a cause of aspi rat i on.(App I I ) J ackkni f i ng was di scarded l ong ago as i t di d not- expel water f romthe l ungs. (See Annal s of Emergency Medi ci ne, 1981)

5. You sent t he Conf erence Steer i ng Commi t tee my l ett er of August 19, i naccur

atel y desi gnat i ng my statements as a "mi nor i ty" opi ni on.

Of t he three par t i ci pant s on your panel , Dr . Model l and I agreed, bef ore anaudi ence at your open panel meet i ng, that the Hei ml i ch Maneuver shoul d beused i n drowni ng. Dr . Model l recommended that mouth- t o- mouth be per f ormedf i r s t , and I agreed. You conf i rmed, bef ore the ent i re conf erence and i nt he f i rst wr i t t en r eport to your panel , t hat use of t he Hei ml i ch Maneuveri n drowni ng was your panel ' s concl usi on. Gi ven three panel member s, whoare the secret "maj ori t y" who reversed that recommendati on?

You state i n your l ett er that I mi sunderstood the process f or revi si on of t heSt andards f or CPR. On the cont rary, I am very f ami l i ar wi t h t hi s process. Tenyears ago, I observed a panel si mi l ar to yours i nduce the Ameri can Red Cross torecommend backsl aps f or choki ng, despi t e medi cal r eferences extendi ng over 130years t hat reveal ed the dangers of t hat t reatment . That Red Cross panel basedi t s r epor t t o i t s St eer i ng Commi t tee on personal bi as rather than sci ent i f i cevi dence, as at test ed to by Dr . J ames J ude, a Red Cross advi ser on CPR for morethan 25 years. I n the of f i ci al t apes of the Dal l as 1985 Conf er ence, Dr' , J udereveal s:

"I was a member of the Nati onal Research Counci l Meet i ng on the Ai r way Management , I thi nk i t was 7 or 8 years ago and t hi s probl em wasdi scussed. Dr . Gordon was there, Dr , Gui l dner, Ther e was no quest i onthat t he deci si on at t hat t i me was that t he abdomi nal t hrust maneuverwas probabl y as good as or perhaps t he best but had not def i ni t el ybeen establ i shed whether or not the back bl ow was of val ue or not. of

val ue. The real reason that apparent l y t here i s a mi sconcept i on thatt he abdomi nal t hrust maneuver i s not a good maneuver i s r eal l y i s whati t ' s cal l ed. . . . i f we get ri d of our personal i t y conf l i cts, and wecal l i t what i t shoul d be cal l ed, an abdomi nal t hrust maneuver , a descr i pt i ve maneuver , whi ch i s absol utel y no di f f erent than a Hei ml i chManeuver t hen i ndeed we -woul dn' t have had t o st ay up t i l l 2: 00 AM i nthe morni ng at that part i cul ar meet i ng i n Washi ngton i f we di d nothave a l ong debate over what i t was to be cal l ed. "

An ar t i cl e, "The Bi opol i t i cs of Choki ng", publ i shed i n t he Utah St at e Medi calJ ournal by Dr . Harry Gi bbons, Di rector of Heal th. Sal t Lake Ci ty and Count y,provi des addi t i onal i nsi ght as to the worki ngs of your organi zat i on.

Dur i ng that ten year per i od, other panel s perpetuated t he backsl ap error. At

the J ul y 11-13, 1985 Dal l as Conf erence, cosponsored by t he Red Cr oss, backsl apswere el i mi nated as a t reatment f or choki ng. The repor t s of compl i cat i ons anddeaths i n choki ng adul t s and chi l dren f ol l owi ng back bl ows, t hat occurred i nthat ten year per i od, and the sci ent i f i c basi s f or t hose acci dent s, were pr esented at t he 1985 Dal l as Conf erence and are reported i n medi cal j ournal s. I twas as a resul t of t hose deat hs, t hat backsl aps were el i mi nated and the Hei ml i ch Maneuver was recommended as the sol e f i rst ai d t reatment f or choki ng.

That same process i s now evi dent i n regard to the t reatment of drowni ng. Re

grett abl y, i n 1960, t he Red Cross was i nduced by i ts advi sers t o adopt mout h-

to- mouth resusci t at i on as the f i rst t reatment f or drowni ng, and previ ousl y ap~


13/24

Joseph P. Ornato, M.D.September 20. 1985Page 6

proved methods that expelled water from the lungs were discarded. The importance of expelling water from the lungs was not appreciated at that time. Youcan not get air into the lungs until you get the water out. For more than 20years,deaths from drowning have increased annually, at present exceeding8,000

per year.

The scientific error of not evacuating water from the lungs, that dates back 25years, must be admitted and corrected. Published scientific evidence provesthat a large amount of water is aspirated by 80-90 percent of drowning victims,up to 1000 cc in a 100 lb person according to Dr. Modell, and that the Heimlich

Maneuver expels that water from the lungs. Your panel recommended that theHeimlich Maneuver be used in the treatment of drowning in order to expel waterfrom the lungs. We can not wait another five years, as suggested by Dr. Modellat your panel meeting, for your "group" to acknowledge the scientific evidencethat already exists. (See transcript of official Conference tapes)

Finally, your statement concerning our conversation is misquoted and out ofcontext, therefore, is flatly rejected. You express anger over my havingdis

seminated correspondence regarding your report to officials. Secrecy and anonymity have no place in medical science. I see no cause for concern or angerabout a scientific report being scrutinized by other scientists, officials~orthe press, provided it is accurate and complete. Isalong wi t hmany physicians, scientists and publ i c heal th of f i ci al s, am determi ned to prevent onemore unnecessar y drowni ng or choki ng death. To accompl i sh t hat goal , the

t ransact i ons l eadi ng t o Aner i can Ravailable to any i nterested par t y,

Cross f i rst ai d i nstr ucts wi l l made

Any recommendat i on by the Conf erence Steer i ng Commi t tee f or the t reatment ofdrowning will be invalid as it will be based on an inaccurate and incompletereport of your panel ' s concl usi ons. Through a copy of t hi s l et t er , I amadvi si ng the Conf erence Steer i ng Corsrj i ttee t hat shoul d i t sccept your repor t , rather

than the scientific f acts presented at t he open meet i ngs, I reserve the r i ghtto include an expository report in any written or published document that i sproduced.

Sincerely,

HJH/jhEnclosurescc: R. Albarran-Sotelo, H. D. ,

Conference Steer i ng Commi t teePresident, American Red Cross

Dean, Medical College of VAPresident, VA Commonwealth Univ,J. M. Fattu, K. D. . Ph. D.R. Mendel sohn, M. D.T. Hughes, M.D.

''Henry J. her I ch, M. D.

W. H Montgornery, M.D.President, Am. College of CardiologyPresident, Natl.Hear t , Bl ood &Lung I nst .

President, American Hear t Associ at i onH. Gi bbons, M. D,E. A. Pat r i ck, M.D.,Ph. D.R. Day, M.D.J. HendricksonInterested parties


14/24

^ ^ Medical College of VirginiaVMW Virginia Commonwealth University

November 11, 1985

Henr y J . Hei ml i ch, MDProf essor of Advanced St udi esXavi er Uni ver si t y3800 Vi ct ory Par kwayCi nci nnat i , Ohi o 45207- 1096

Dear Dr . Hei ml i ch:

I n r esponse t o your l et t er of Sept ember 24, I must agai n emphasi ze t hat t he J ul y St andards Conf erence meet i ng r ecommendat i ons

ser ve as an i mpor t ant , but not excl usi ve, sour ce of i nput f or t hedevel opment of t he new CPR St andar ds and Gui del i nes. Your bel i ef s r egar di ng t he necessi t y t o per f or m an abdomi nal subdi a-phr agmat i c t hr ust f or t he near - dr owni ng vi ct i m ar e subj ect t o t hesame peer r evi ew pr ocess as al l other mater i al pr oposed f ori ncl usi on i n t he St andar ds and Gui del i nes. Your peer s on t hepanel do not consi der t he sci ent i f i c evi dence adequate at t hi st i me t o suppor t r ecommendat i on of a subdi aphr agmat i c t hr ust f orthe- near - dr owni ng vi ct i m who has no evi dence of f orei gn bodyai r way obst r uct i on. Much of t he evi dence you r ef er t o as suppor t i ng your posi t i on ei t her consi st s of anecdot al i nf or mat i on ,ori s si mpl y not wher e you say i t i s i n t he l i t er at ur e.

Pl ease f i nd encl osed a phot ocopy of al l t he r ef erences whi ch youci t ed i n your 1981 Annal s of Emer gency Medi ci ne ar t i cl e ( wi t h t heexcept i on of t he t wo Fi r st Ai d manual s and t he t wo revi ew t ext books, whi ch ar e too bul ky to r epr oduce and cont ai n no or i gi nalpeer- r evi ewed data on t hi s subj ect) . You cl ai m t hat t he commi t t ee i gnored t hese ref er ences v/hi ch you bel i eve suppor t yourposi t i on. The commi t t ee member s ar e f ami l i ar wi t h t hi s l i t er at ur e and cannot f i nd the evi dence i n any of t he publ i cat i ons youhave ci t ed whi ch support s your bel i ef t hat a subdi aphr agmat i ct hr ust i s saf e or ef f ect i ve for t he near - dr owni ng vi ct i m who hasno evi dence of f orei gn body ai r way obst r uct i on. Ther e ar e no.pr ospect i ve or r et r ospect i ve, r andomi zed or non- r andomi zedst udi es i n humans or ani mal s whi ch deal wi t h t hi s subj ect .

The si x cases you ment i on i n your 1981 Emergency Medi cal Ser vi cesar t i cl e are test i moni al s wi t h l i t t l e support i ng cl i ni cal i nf or mat i on about whi ch to j udge t hei r si gni f i cance. The r epor tappear s i n a j our nal whi ch cont ai ns ar t i cl es of an i nf ormal , nonr i gor ous st yl e. Ther e i s no i nf or mat i on i n t he ar t i cl e about howt hese anecdot es wer e col l ected ( sol i ci t ed or unsol i ci t ed i nf or -

Seetion of Emergency Medical Services P.O. Box 525 Richmond, Virginia 23298-0001


15/24

Page 2

mat i on) , whet her t he r escuer s were i ntervi ewed and by whom, t he

l evel of t r ai ni ng of t he r escuer s, whet her mout h- t o- mout h wast r i ed by a t r ai ned rescuer f i r st , t he pat i ent s age, sex, ci r cumst ances of t he near - dr owni ng i nci dent , dur at i on of i mmer si on,f r esh vs. sal t wat er .- to ment i on but a f ew of t he many r el evant var i abl es. Ther e i s no evi dence t hat t he f l ui d comi ng outof t he mout h di dn' t come f rom t he st omach.

These anecdot es may be of i nt erest but do not const i t ut e sci ent i f i c pr oof , at l east not i n t he f or m t hey ar e document ed. Thi si nf or mat i on i s i nsuf f i ci ent to r ecommend r epl aci ng i mmedi at emout h- t o- mout h vent i l at i on wi t h a subdi aphr agmat i c t hr ust whent her e ar e over 80, 000 near - dr owni ng i nci dent s i n t he Uni t edSt at es per year and onl y 8, 000 deat hs wi t h t he cur r ent r ecom

mendat i ons. Ther e are many unknowns about t he saf ety of a subdi aphr agmat i c t hr ust i n t hi s set t i ng such as t he number of t i mesa subdi aphr agmat i c t hr ust has been t r i ed f or a near - dr owni ngvi ct i m and f ai l ed, t he number of t i mes i t has been t r i ed andr esul t ed i n aspi r at i on f rom ej ect i on of gast r i c cont ent s, t henumber of l i ves whi ch mi ght be l ost because of t he del ay i npr ovi di ng mout h- t o- mout h vent i l at i on i f a subdi aphr agmat i c t hr ustwer e per f or med f i r st and i t i s unsuccessf ul t o ment i on but af ew. These i mpor t ant f act s ar e unknown . because t her e i s no dat a.

The best t hat can be concl uded f r om a sci ent i st ' s per spect i ve i st hat f ur t her st udy needs t o be done.

Pl ease l ook over t he mat er i al you ci t ed agai n, under l i ne i n redt he evi dence you ar e r ef er r i ng t o, and ret ur n t he mat er i al t o meso the commi t t ee can under st and what you consi der to be pr oof oft he saf et y or ef f i cacy of a subdi aphr agmat i c t hr ust i n t hi sset t i ng.

You have al so cl ai med t hat t her e ar e addi t i onal case r epor t s i nt he J our nal of t he Amer i can Medi cal Associ at i on ( J AMA) and ot herj our nal s, yet nei t her you nor Dr . Pat r i ck r ef er r ed t o any suchcases i n your publ i cat i ons. Nei t her I nor ot her member s of t hecommi t t ee ar e f ami l i ar wi t h such case r epor t s. I coul d not f i ndany such case r epor t s despi t e a search t hrough I ndex Medi cus andt he i ndexes t o J AMA f or t he l ast t went y years (a copy of t he

i ndex sect i on on "Dr owni ng" f or t he l ast t went y year s of J AMA i sencl osed) . I f you have such an ar t i cl e whi ch has been over l ooked, pl ease send a copy of i t or send a speci f i c ci t at i on soi t can be r evi ewed.

Dr . Model l has poi nt ed out t hat you have mi si nt er pr et ed hi sst udi es and hi s publ i cat i ons whi ch deal wi t h aspi r at i on of wat er


16/24

Page 3

by t he near - dr owni ng vi ct i m. Thi s mat er i al , deal i ng wi t h t hequant i t y of wat er aspi r at ed by a near - dr owni ng vi ct i m, i scr i t i cal t o your argument . ' I have encl osed a copy of t he l et t erf r om Dr . Model l whi ch poi nt s out hi s di sagr eement wi t h youri nt er pr et at i on of hi s dat a.

Encl osed pl ease f i nd l et t er s f r om t he ot her member s of t he paneli ndi cat i ng t hei r suppor t of t he l at est ver si on of t he dr af tdocument . You wi l l not e t hat your posi t i on j i s a mi nor i t yopi ni on. Si nce you were upset by t he l ack of acknowl edgement ofyour mi nor i t y opi ni on i n t he dr af t document , I cal l ed Dr . Model land di scussed the mat t er wi t h hi m. He suggest ed addi ng t hef ol l owi ng ( under l i ned) sent ence t o t he l ast por t i on of t he sec

t i on ( t he sent ence pr i or to and f ol l owi ng t he pr oposed sent encear e i ncl uded t o make cl ear t he cont ext of t he addi t i on) :

"Si nce t he r i sk/ benef i t r at i o of an abdomi nal t hrust i n t hi sse- tt i ng i s unknown, t he onl y t i me i t def i ni t el y shoul d beused i s when the r escuer suspect s t hat f or ei gn mat t er i sobst r uct i ng t he ai r way" . However , some bel i eve that i f t hevi ct i m does not r espond appr opr i at el y t o mout h to mout hvent i l at i on, a subdi aphragmat i c abdomi nal t hr ust may bei ndi cat ed, af t er whi ch basi c CPR shoul d be r ei nst i t ut ed.

Fur t her i nvest i gat i on i s needed to bet t er def i ne the need

fo r , the r i sk of , and t he t i mi ng of , an abdomi nal t hrust i nthi s si t uat i on. "

I have phoned al l t he ot her panel member s, who have no obj ect i onto f or war di ng Dr . Model l ' s addi t i on to Dr . Rami r o Al . barran-Sot el o, who i s i n charge of t he next st ep i n t he revi ew andwr i t i ng pr ocess of t hi s sect i on.

Very tr ul y your s,

J oseph P. Or nat o, MD, FACC

Associ at e Pr of essor of I nt er nal Medi ci ne ( Car di ol ogy)

cc: R. Al bar r an- Sot el o, MD R. Day, MDConf er ence St eer i ng Commi t t ee T. - Hughes, MD

Pr esi dent , Vi r gi ni a Commonweal t h H. Gi bbons, MDUni ver si t y J . Hendr i ckson

Pr esi dent , Amer i can Col l ege of R. Mendel sohn, MDCar di ol ogy W. H. Montgomer y, MD


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Page 4

Pr esi dent , Nat i onal Hear t , Bl oodand Lung I nst i t ut e

Pr esi dent , Amer i can Red Cr ossPr esi dent , Amer i can Hear t Associ at i onDean, Medi cal Col l ege of Vi r gi ni a

J . M. Fat t u, MD, " Ph. DE. A. Pat r i ck, MD, Ph. D

Encl osur es


18/24

WIEKUNIVERSITY Henry J. Heimlich, M.D.

Prof esso r of Advanced Clinical Sciences

November 20, 1985

Joseph P. Orn ato, M.D. yl$Medical College of VirginiaVirginia Commonwealth UniversityP.O. Box 525Richmond, VA 23298-0001

Dear Dr. Ornato:

Your l et ter of November 11, 1985 ( recei ved 11/ 18/ 85) and the encl osures con

f i rm the f acts stated i n my l et ter to you of September 24, 1985. Af ter cut t i ngthrough t he rhet ori c, I note that , on Dr . Model l ' s suggest i on, you have nowrestored the Hei ml i ch Maneuver to the protocol f or t reat i ng a drowni ng vi ct i m.Agai n, however , your report must be consi dered di si ngenuous and i ncompl ete.

You now recommend the f ol l owi ng st atement :"Si nce the r i sk/ benef i t rat i o of an abdomi nal thrust i n thi s set t i ng i sunknown, t he onl y t i me i t def i ni tel y shoul d be used i s when t he rescuersuspects that f orei gn mat ter i s obst ruct i ng the ai rway". However , somebel i eve that i f the vi cti mdoes not respond appropr i atel y to mouth tomouth vent i l at i on, a_ subdi aphragmat i c abdomi nal t hrust may be i ndi cat ed, af ter whi ch basi c CPR shoul d be rei nst i t ut ed. (emphasi s your s)

Fur ther i nvest i gat i on i s needed to bet ter def i ne. the need f or , t he r i skof , and t he t i mi ng of , an abdomi nal thrust i n thi s si tuat i on. "

That st atement i s decept i ve. The maj or i t y of your panel , not "some, " agreedat the Dal l as conf erence (of f i ci al conf erence tapes) and al so i n the post -conf erence l et t ers you di str i buted wi th your l et ter of November 11, t hat theHei ml i ch Maneuver i s the recommended procedure when t he drowni ng vi ct i m doesnot respond promptl y to mouth-to-mouth; not one panel member obj ected t o thatconcl usi on. Fur t hermore, you agai n conceal the vol ume of water aspi rated bythe drowni ng vi ct i m and, theref ore, the need to evacuate t hat wat er .

Your unreasonabl e ment i on of the r i sk/ benef i t rati o of the Hei ml i ch Maneuver ,i s a red her r i ng. There i s no si gni f i cance to the r i sk/ benef i t rat i o i n thedrowni ng vi ct i m who has not responded prompt l y t o mout h- t o-mout h, si nce theal ternat i ve i s deat h. You seem to be concerned t hat as the Hei ml i ch Maneuverwi l l save l i ves, i t wi l l agai n prove the error of the ARC/ AHA advi sers for notreal i zi ng the need to expel water f rom the l ungs. Newer, more advanced l i f e-savi ng concept s can not be wi thhel d i n order to conceal that sci ent i f i c er ror .

3800 Vi ctory Par kwayCi nci nnat i , Ohi o 45207- 1096

533/531-1053


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Your f i rst r eport , J ul y 22, 1985, sent to the t hree part i ci pants on your panel ,Drs. Model l , St ei nman, and mysel f , whi ch accurat el y descr i bes our concl usi ons,i s as f ol l ows:

NEAR- DROWNI NG -The most i mportant consequence of prol onged underwater submersi on

wi thout vent i l at i on i s hypoxemi a. I ni t i al l y t here i s breath- hol di ng,f ol l owed by swal l owi ng l arge amounts of water , vomi t i ng, termi nal gaspi ng wi th f l oodi ng of the l ungs, and deat h. Aspi rat i on of a moderateamount of water (up to 22 ml / kg body wei ght ) occurs i n 88- 90 percent ofdrowni ngs; 10- 12 percent of vi ct i ms do not . aspi rate due t o l aryngo-spasm. . . ' .

5. Once the vi ct i m i s out of the wat er , i f :a) adequate vent i l at i on i s not achi eved wi th rescue breathi ng and

the vi ct i m does not respond despi te repeated at tempts wi th aproper head and j aw posi t i on; or

b) there i s evi dence of ai rway obst ruct i on;

then an abdomi nal thrust as descri bed by Hei ml i ch i s i ndi cated,

For compl eteness and accuracy, the sequence shoul d then read:

Some recommend t hat the Hei ml i ch Maneuver be used f i rst to expel wateryvomi t us, and debr i s f rom the l ungs. ( 1- 5, 7) Ot hers are concerned thatthe Hei ml i ch Maneuver may cause aspi rati on of st omach contents i f usedas the i ni t i al t reatment for drowni ng. ( 6)

Your J ul y 22 report wi th the addendum i s i n keepi ng wi th your panel ' s recommendati ons and the concl usi ons you presented at t he pl enary sessi on of t he conf erence as recorded on the of f i ci al conf erence t apes. (I t woul d be more accuratei f you had not ' modi f i ed Dr . Model l ' s descr i pt i ve words, that the Hei ml i ch Maneuver shoul d be used i f the near- drowned vi ct i m "does not respond prompt l y"to mouth- to- mouth) (See of f i ci al conf erence t apes: avai l abl e f rom Eastern Audi o Associ at es, I nc. , 6330 Howard Lane, El kr i dge, MD 21227)

You of f er no post - conf erence ref erence or sci ent i f i c evi denca that warrants -changi ng your J ul y 22 report wi th my addendum added. As stated above, t hemaj or i t y of your panel i s i n agreement wi th that r eport ; not one obj ects. Thel et ters you encl osed on November 11, 1985 conf i rm thi s f act .

Dr . Model l ' s l et ter of October 1_8, 1985, to Dr ^ Ornat o:Dr . Model l conf i rms hi s cont i nui ng agreement wi t h me, as he stated at the Dal l as conference panel meet i ng, that the Hei ml i ch Maneuver shoul d be used when

t he drowni ng vi ct i m does not respond prompt l y t o mout h- to-mouth. Dr . Model land I const i tute t he maj or i ty of the panel of t hree par t i ci pants.

Your or i gi nal report of J ul y 225, 1985 (except f or the absence of the words"does not respond promptl y") "pl us my addendum are compl ete and accurate st atement s consi stent wi th the sci ent i f i c deci si on of t he maj or i t y of your panel ,your repor t to the conf erence, and Dr . Model l ' s l et ter to you of October 18,1985. .

Dr . Stei nman' s l et ter of October V2L 1985 to Dr ^ Ornat o:

Dr . Stei nman expresses concern wi th the use of t he Hei ml i ch Maneuver as a., f i r st


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st ep i n t reat i ng drowni ng, but does not comment on i ts use after mout h- to- mouthfai l s. That was hi s posi t i on at the panel meet i ng and i t does not requi real terat i on of your ori gi nal J ul y 22 report wi th my recommended addendum.

Once agai n, no panel member di sagrees wi th t he r ecommendati on that the Hei ml i ch

Maneuver be used when the drowni ng vi ct i m does not respond t o mout h- t o-mout h,and the maj or i t y support t hat concl usi on.

Dr . Nemi rof f ' s l et ter of October 18, 1985 tor Dr . Ornat o;Dr . Nemi rof f , who was not a member of the panel , states i n hi s l et ter that hi ssubordi nat e, Dr . St ei nman, was hi s personal representat i ve and that they are i nagreement . The statement above concerni ng Dr . Stei nman' s vi ewpoi nt , t heref ore, ,stands.

Dr . Nemi rof f l i sts i n det ai l the i tems i n r ay l et ter of September 24, 1985, concerni ng your act i ons, al l of whi ch are document ed. He then der i des t he reference i n my l et ter to your quot i ng "secret maj or i t i es, " But Dr . Nemi rof f al sodescri bes the process by whi ch your deci si ons were reached. He speaks of con

f erence tel ephone cal l s bet ween hi m, yoursel f , Dr s. Model l , St ei nman, and Mr .Dai l . I t apparent l y di d not st r i ke hi m as bei ng i rregul ar that I was excl udedf rom those conf erence cal l s and recei ved no phone cal l s. Yet , despi t e the f actthat I was kept unaware of these conf erences, Dr . Nemi rof f concl udes that hebel i eves the most recent st atement i n your report ref l ects my vi ews.

Mr . Pai l ' s l et ter of October 25, 1985 t o Dr . Ornat o;Mr . Dai l , a nonmedi cal Red Cross observer , states i n hi s l et ter that he accepts t he panel report attached to your October 8, 1985 memo and refers t o yourphone conversati on on October 12, 1985. I di d not recei ve your memo, a panelreport of that dat e, or a phone cal l f romyou.

I t i s now cl ear that there has bean a secret conf erence and report s i n whi chMr . Dai l , a nonmedi cal Red Cross of f i ci al , part i ci pated i n reachi ng a supposedl y sci ent i f i c deci si on and I , a panel member, was excl uded. As a mat ter offact, I was not aware of your conf erence or deci si ons unt i l t hi s t i me, amonth- and- a- hal f af ter Mr . Dai l ' s par t i ci pat i on. Mr . Dai l may be concernedabout Red Cross l i abi l i ty f or thei r f i rst ai d i nstructi ons whi ch have beendesi gnated as hazardous and l ethal , but that consi derat i on has no pl ace i n t hesci ent i f i c deci si on- maki ng process.

I n rny previ ous l ett er, I quoted the st atement made by Dr . J ames J ude at the1985 Dal l as Red Cross/ Heart Associ at i on Conf erence. He descr i bed a meet i ng,concerni ng the t reatment of choki ng, of a si mi l ar ARC/ AHA commi t tee i n . 1976,that l asted unt i l 2: 00 AM, di scussi ng, not the sci ent i f i c evi dence, but the

name Hei ml i ch Maneuver . (See of f i ci al conf erence t apes) I was not at thatpost - conf erence meet i ng ei t her , but the si mi l ar i t y to the f urt i ve process youand your col l aborators have engaged i n i s obvi ous. The changes made i n yourreport s si nce your or i gi nal J ul y 22 recommendat i ons are i n keepi ng wi th thoseof your predecessors, even to your mani pul ati on of the name of the procedure.

Mr . Dai l al so was a nonmedi cal par t i ci pant i n 1976, at t he meet i ng whi ch perpetuated f or ten years t he r ecommendat i on of back bl ows, chest t hrust s, andabdomi nal thrust s f or the t reatment of choki ng. As you know, on October 1,1985, t he Surgeon General of t he Uni ted States desi gnated those ARC/ AHA . methods as "hazardous, even l ethal " and advi sed the Red Cross, Heart Associ at i on


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and publ i c heal th aut hori t i es that onl y the Hei ml i ch Maneuver shoul d be usedfor the t reatment of choki ng.

Your post - conf erence di scussi ons, f rom whi ch I was excl uded, reached nonsci en-t i f i c concl usi ons and conceal ed previ ous errors. I f such concl usi ons are not

corrected pr i or to publ i cat i on, be assured t hat the sci ent i f i c communi t y, youri nst i tut i ons, and t he publ i c wi l l be made aware of the errors and t he manneri n whi ch they were deri ved, rather than permi t t i ng drowni ng vi ct i ms to be sub

j ected to ten years of "hazardous, even l ethal " measures.

Dr . Model l ' s l et ter speaks of the vol ume of water aspi rated by a drowni ng per son. He obj ect s t o my sayi ng "as much as" 22 ml / kg (10 ml / l b body wei ght ) i saspi rated by drowni ng per sons. (That expressi on actual l y appears i n Dr . Ornat o1s J ul y 22, 1985 repor t . ) Dr . Model l pref ers t o say "l ess t han" 22 ml / kg i saspi rated. No mat t er; both expressi ons prove that up to 1000 ml of water i saspi rated by a 100 l b drowni ng vi ct i m and up to 1500 ml by a 150 l b i ndi vi dual .Those f i gures are based on Dr . Model l ' s st udi es and cannot be conceal ed bywords l i ke "a modest amount " as Dr . Ornat o di d i n hi s f i nal repor t . Dr . Model l

st ates that there i s "a smal l amount of wat er " aspi rated "i n some cases, " butomi ts hi s other publ i shed resul t s, that more than 22 ml / kg of body wei ght wasaspi rated i n 15%of hi s cases. Once agai n, Dr . Ornat o, based on Dr. - Model l ' spubl i cat i ons and hi s l et t er , your J ul y 22 report regardi ng the amount of wateraspi rated, i ncl udi ng "f l oodi ng of the l ungs" is_ correct and must st and, not beconceal ed.

Fur t hermore, every r ai l l i l i t er of water aspi rated by a drowni ng person exacer bates the hypoxi a that causes death. Al l al veol i and bronchi that are bl ockedby wat er, whi ch i s a f orei gn body, produce a shunt bl ood, passes through non-vent i l ated al veol i and returns to the arter i al ci rcul at i on unoxygena ed.Haynes ( 8) st ates, "Hypoxemi a f ol l ows aspi rat i on of smal l amounts of water andi s seen exper i mental l y wi th aspi rat i on of 2, 2 ml / kg . of ei ther f resh water orsal t wat er . " One ml / l b or 100 cc i n a 100 l b i ndi vi dual , whi ch i s one tenththe vol ume of water that Model l ref ers t o, i s suf f i ci ent to cause hypoxemi a.Haynes al so st at es, "Cont r i but i ng to hypoxi a may be aspi rat i on of bacter i a,al gae, sand, par t i cul ate mat t er , emesi s, and chemi cal i r r i t ant s. " That i sanother good reason f or usi ng t he Hei ml i ch Maneuver to evacuate water.

Dr. Hodel l ' s gl ass of water i s mi sl eadi ng, I t i s not the vol ume of the l ungsthat i s si gni f i cant : i t i s how many al veol i or bronchi are obst ructed' andwhere the water i s l ocat ed. An adul t ' s t rachea can be total l y obst ructed wi th150 ml of wat er , prevent i ng any ai r f rom get t i ng t o the l ungs, and t here wi l lsti l l be enough water l ef t over to f i l l t he nose and t hroat .

I n 1981, Dr . Model l wrote an art i cl e ent i t l ed "I s t he Hei ml i ch Maneuver Appropri ate as Fi rst Treatment f or Drowni ng?", and ref erred t o the "Hei ml i ch Maneuver" t hroughout the paper . ( 6) At your panel meet i ng i n Dal l as, he ref erredto the procedure as the "abdomi nal thrust descri bed by Hei ml i ch" as you di d,Dr . Ornat o, i n your concl usi ons reported to the Dal l as conf erence and i n yourwri t ten J ul y 22 report . Your subsequent report s use onl y the words "abdomi nalthrust. " Now you and Dr . Model l use "subdi aphragmati c abdomi nal t hrust . " Areader of your l et t ers and report s wi l l very l i kel y be cur i ous as t o t hesef requent changes; t he ARC/ AHA i nst ructors and st udents wi l l undoubtedl y betotal l y conf used. The f ol l owi ng background cl ar i f i es the mot i ve behi nd t hesebl atant i nconsi stenci es.


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I n 1971*, edi t ors of the J ournal of t he Amer i can Medi cal Associ at i on ( J AMA)named the Hei ml i ch Maneuver and, i n 1975, t he Hei ml i ch Maneuver was of f i ci al l yendorsed as such by an AMA commi ssi on. The Red Cross adopted t he Hei ml i ch Maneuver as a t reatment f or choki ng i n 1976 but al so r ecommended back bl ows andchest t hrust s; I i mmedi atel y deni ed t he Red Cross use of my name as I di d not

wi sh my method t o be bl amed for t he deaths that occur red. The Red Cross,t heref ore, has used t he name "abdomi nal t hrust . " On October 1, 1985, the Sur geon General of the Uni ted States i ssued a rel ease stat i ng abdomi nal thrust sare "hazardous, even l ethal . " Surgeon General Koop wrote that "abdomi nalthrusts, because they r ef er to bl ows to unspeci f i ed l ocat i ons on the body, haveresul ted i n' cracked r i bs and damaged spl eens and l i ver s, among other i nj ur i es.The best rescue t echni que, " Dr . Koop sai d, "i s the Hei ml i ch Maneuver . " Dr s.Model l and Ornat o now appear to be respondi ng to the Surgeon General ' s di r ect i ve by cal l i ng the Hei ml i ch Maneuver a "subdi aphragmat i c adbomi nal t hrust , "rather than accept i ng hi s of f i ci al recommendat i on.

I n J ul y 1985, I advi sed the presi dent of the Red Cross t hat , si nce back bl owsand chest t hrust s have been wi t hdrawn, they may now use t he name "Hei ml i ch Man

euver . "

You descri be your f rui t l ess search "through I ndex Medi cus and the i ndexes- toJ AMA for the l ast twenty years" for documented case report s i n J AMA, and concl ude that the evi dence "i s not where you say i t i s i n the l i t erature. " AsDr. Pat r i ck i nf ormed you i n hi s l et ter of September 4, 1985, af ter he answeredyour equal l y defamatory f al se accusati ons concerni ng hi s pat i ent care and publ i shed r eport , "You shoul d have tel ephoned or wr i t ten t o me f or thi s i nf ormat i on. " You cannot e.scape the obj ect i ve evi dence that exposes sci ent i f i cerrors by i gnor i ng i t s documentat i on i n sci ent i f i c publ i cat i ons or by notseeki ng the ref erences f rom the source. The sci ent i f i c r ef erences that f ol l oware readi l y avai l abl e to you.

You are i n possessi on of a repr i nt of the work of Edward A. Pat r i ck, M. D. ,Ph. D. and have ref erred to i t , al bei t i gnomi ni ousl y, i n your l et ter of August23, 1985, yet egregi ousl y omi t ref err i ng to i t i n your November 11th l et t er .Dr. Pat r i ck, Prof essor of El ectr i cal and Computer Engi neer i ng, Uni versi ty ofCi nci nnati , who i s al so an emergency medi ci ne physi ci an, reported a studybased on a prospect i ve protocol . Dr . Pat r i ck documented that the Hei ml i chManeuver expel l ed water f rom the l ungs of a two- year- ol d drowni ng vi cti m whorecovered as a r esul t . The chi l d had been submerged i n a l ake for 20 mi nut es,had mouth- to-mouth and baggi ng for 20 mi nut es, and was i ntubated and sucti onedwi thout avai l . The Hei ml i ch Maneuver expel l ed water f rom the l ungs, as evi denced by i t s emergence f rom the endot racheal t ube, r esul t i ng i n breath soundsnot previ ousl y present and subsequent recovery. (1) Shoul d, you omi t thi s

ref erence f rom t he AHA report to be publ i shed i n J AMA, i t wi l l i dent i f y thatAHA report as bei ng decept i ve and i ncompl ete.

The J AMA reference you coul d not f i nd appears i n I ndex Medi cus under "Hei ml i ch, HJ . " That was my f i rst def i ni t i ve paper on the Hei ml i ch Maneuver . Thatar t i cl e and another publ i shed i n Cl i ni cal Symposi a quote f rom a report byVi ctor Esch, M. D. , Chi ef Fi re Surgeon, Washi ngt on, DC, and advi ser on watersaf ety to the Red Cr oss, who al so provi ded detai l ed document at i on. Dr . Esch,an emi nent medi cal author i t y on drowni ng, document s the case of an apnei c,unconsci ous drowni ng vi ct i m brought ashore by a l i f eguard. He used the Hei ml i ch Maneuver , water gushed out the mout h, and t he vi ct i m recovered. Dr . Esch


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J oseph p, .";.'nato, MD.November 20, 1985Page 6

st at ed t hat he pr oved t her e was wat er i n t he l ungs and sai d, "I t [ t he Hei ml i chManeuver ] may open up a new vi sta of resusci t at i on. I t does no good t o dost andard mout h- t o- mout h br eat hi ng i f there i s wat er i n t he l ungs or debr i s i nt he t r achea f r om vomi t i ng. The ai r won' t get t hr ough. " ( 2, 3)

The si x cases t hat you ment i on i n your l et t er , wher e t he Hei ml i ch Maneuversaved drowni ng vi ct i ms, and addi t i onal cases ot her t han t he t wo descr i bedabove, wer e document ed i n r epor t s f r om hi ghl y qual i f i ed emer gency medi calt echni ci ans, par amedi cs, l i f eguar ds, and one s ci ent i s t , a f act so r epor t ed i nthe l i t erature . (2, 3, 4, 5) I n no known i nst ance has t he Hei ml i ch Maneuverr esul t ed i n vomi t i ng or aspi rat i on.

Anot her sci ent i f i c paper known t o you ci t es el even ref erences document i ng t hati nt er mi t t ent upward pr essur e on t he di aphragm, as i n t he Hei ml i ch Maneuver ,expel s wat er f r om t he l ungs. (5)

Mout h- t o- mout h was i nt r oduced i n 1960 and dr owni ng deat hs have i ncreased ever yyear t her eaf t er . You stat e t hat t her e are 80, 000 near- dr owni ng "i nci dent s" per

year i n t he Uni t ed States and 8, 000 f at al i t i es. You may wi sh t o document howmany of t he 80, 000 were unconsci ous and apnei c, t hen revi ved af t er mout h- t o-mout h, and t he number who r equi r ed no emer gency t r eat ment and r ecover ed spont aneousl y. That exer ci se i s not r eal l y necessary si nce no one i s suggest i ngt hat mout h- t o- mout h be abandoned: t he rescue br eat hi ng t echni que i s ext r emel yval uabl e pr ovi di ng i t i s not rel i ed dn t o t he excl usi on of t he Hei ml i ch Maneuver. I n any case3 your panel agr ees t hat some of t he 8, 000 deat hs can beprevented by usi ng t he Hei ml i ch Maneuver .

Those who f or mul at e t he r ecommendat i ons f or t he Red Cr oss and Hear t Associ at i onmade a sci ent i f i c er r or 25 year s ago i n not expel l i ng wat er f rom t he l ungs, ofdr owni ng vi ct i ms. To now conceal and perpetuate that er ror by denyi ng t hataspi r at ed wat er ' causes hypoxi a i n dr owni ng vi ct i ms wi l l di mi ni sh t he c r edi bi l i t y of t hei r own i nst i t ut i ons, whi ch are r esponsi bl e f or r evi ewi ng and aut hent i cat i ng t he sci ent i f i c deci s i ons of t hei r st af f . These i nst i tut i ons i ncl udeuni vers i t i es , hospi t al s , t he Coast Guar d, t he ARC, and t he AHA, al l of whi char e publ i cl y f unded, t her ef or e r esponsi bl e t o t he publ i c .

The compet ence of t he pr ocess used by t he AHA/ ARC and the content of t hei rf i r s t ai d i nstr uct i ons i s bei ng cal l ed i nt o quest i on by event s descr i bed i nt hi s l et t er , document at i on i n t he of f i ci al Dal l as conf er ence t apes, your r eports and l et t er s , and the post - conf er ence l et t er s you encl osed i n your l et t erof November 11, The cl andest i ne pat t er n of oper at i on reveal ed i n t he pr ocess bei ng used t o det ermi ne t he t r eat ment of drowni ng i s consi st ent wi t ht hat pr evi ousl y used t o der i ve t he t r eatment of choki ng. That modus oper and!

l ed, i n t he Sur geon General ' s wor ds, t o " hazar dous, even l ethal " r ecommendat i ons by t he ARC/ AHA.

Si mi l ar pr act i ces resul t ed i n per si st ent er r or s i n r ecommended CPE t echni ques.A subst ant i al number of physi c i ans, sci ent i sts , and publ i c heal t h aut hor i t i esar e concer ned wi t h t hi s si t uat i on. We ar e pr epared t o seek f ur t her i nvest i gat i on of ARC/ AHA met hods shoul d t he ARC/ AHA not i ns i st t hat i t s r epr esent at i vesabi de. by est abl i shed obj ecti ve sci ent i f i c pr ocedur es. Mot one more l i f e mustbe l ost unnecessar i l y.

Your compl et e J ul y 22 repor t wi t h my addendum i s an accur at e and compl ete r ep-


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resentat i on of sci ent i f i c knowl edge and your panel ' s maj or i t y deci si on.Shoul d you choose to al ter the wordi ng so as t o di mi ni sh support f or the useof the Hei ml i ch Maneuver , those who part i ci pate i n that nonsci ent i f i c deci si onwi l l be l i abl e for drowni ng deaths f ol l owi ng the unsuccessf ul use of mout h- t o-mout h. My posi t i on i s on record i n regard to the sci ent i f i c f acts and the

process taken by you and your col l aborators.

REFERENCES

1) Pat r i ck, EA: The Hei ml i ch Manuever . Emergency 13:45, 1981.2) Hei ml i ch, * HJ : A l i f esavi ng maneuver to prevent f ood- choki ng. J AMA 234: 398,

1975.3) Hei ml i ch, HJ : The Hei ml i ch Maneuver . Cl i ni cal Symposi a 31: 3, 1979.4) Hei ml i ch, HJ : The Hei ml i ch Manuever : f i rst t reatment f or drowni ng vi ct i ms.

Emerg Med Serv 10: 58, 1981.5) Hei ml i ch, HJ : Subdi aphragmat i c pressure to expel water f rom the l ungs of

drowni ng persons. Ann Emerg Med 10: 476, 1981.6) Model l , J H: I s t he Hei ml i ch Manuever appropr i ate as the f i rst t reatment f or

drowni ng? Emerg Med Serv 10: 63, 1981.7) Hei ml i ch, HJ : Edi tor i al Commentary. Emerg Med Serv 11: 93, 1982.8) Haynes, BE: "Near Drowni ng. " Ch. 50 i n Emergency Medi ci ne, ed. by

Ti nti nal l i , J E et al . (New York: McGraw Hi l l , 1985) , p. 383.

HJH/jh ^

ec2 R. Albarran-Sotelo, M.D.,Conference Steering Committee

President, American Red CrossDean, Med. College of VirginiaH. Gibbons, M.D.J. M. F a t t u , M.D., Ph.D.R. Mendelsohn, M.D,T. Hughes, M.D.Commandant, U.S. Coast GuardI n te r e s t e d pa r t i e s

W. H, Montgomery, MD.Pr es id en t, Am. Coll ege of Cardi ologyPresident, Mat'l Heart, Blood, Lung Inst.Pr es id en t, American Heart As soci atio nPresident, Virginia Commonwealth Univ.E. A. Patrick, M.D., Ph.D.R. Day, M.D.J . Hendr i cksonPresi dent , Uni versi ty of Fl or i da

my father's bizarre 1985 correspondence with american heart association committee chair joe ornato...

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