José Lázaro González
Servicio de Urgencias. Hospital Virgen de la Concha. Complejo hospitalario de Zamora (Spain).
Correspondence: José Lázaro González: Avda. Cardenal Cisneros, 39-6º A – 49011 Zamora (Spain).
Recieved 9 January 2007; modified and re-sent 19 November, 2007; accepted 27 December 2007
The Heimlich manoeuvre is a technique aimed at clearing the windpipe when it has become blocked by a foreign body. It is a lifesaving manoeuvre, such that since it was first described it has been considered the simplest manoeuvre (it does not require technical media) that most lives has saved in the world. Easy to learn and use, it is recommended in all the manuals on Basic Life Support (although in the most recent guides it is not cited as such) for health staff and non-health workers alike; it would be good to see the learning of this technique spread farther afield, above all to those people prone to having to use it (health workers and first interventionists). Several films, often comedies, have included it in their plots and knowledge of the technique is important when considering its possible use for education and dissemination purposes.
Keywords: Heimlich manoeuvre, FBAO, Cinema.
FBAO is an infrequent cause of death but can be prevented. It is calculated that in the United Kingdom 16,000 cases occur annually, of which only 1% end in tragedy1. In the USA, there are between 350-2,000 deaths a year caused by such accidents2. In Spain, the death of the actress Luisa Sala, who choked while eating (DOD, 16/06/1986)3 caused much commotion. It is indeed a medical emergency.
The situation is more common in children, above all those between the ages of 1 and 4, toys being the main culprits2. In adults, FBAO usually occur when people are eating, and meat is the most common cause of obstruction, although other foods and foreign bodies are also responsible for the same picture in both children and some adults. The most common factors associated with choking on food are people’s attempts to swallow large, poorly chewed chunks, keeping foreign bodies in the mouth while working, and dental prostheses. Elderly people with dysphagia are more prone to suffering an episode of FBAO2,4.
The condition should be suspected when a person suddenly shows difficulties in breathing, turns cyanotic and/or loses consciousness for no apparent reason. When the obstruction is not complete, the victim usually remains conscious and may cough energetically, although it is sometimes possible to hear whistling between the coughing attacks. When the obstruction is complete or sufficiently severe to interrupt gaseous exchange, the patient develops a weak and ineffective cough, inspiratory sibilance, increasing difficulty in breathing, cyanosis, and finally loss of consciousness. In these cases, the patient is unable to talk, breathe or cough energetically and may well make the universal sign of choking (encircling his/her throat with the thumbs in a C shape)5 (Figure 1).
If the obstruction is only slight, the person attending should encourage the individual to cough violently, without interfering in the spontaneous coughing of the victim or in his/her attempt to breathe.
If the obstruction is severe, it is necessary to activate the emergency system as fast as possible. In adults and children older than 1 who are conscious, the effectiveness of gentle thumps on the back has been demonstrated, as have rapid abdominal compressions (the Heimlich manoeuvre) and compressions with dry thrusts to the thorax (a variation on the Heimlich manoeuvre in which the resuscitator and his/her hands are in the same position but the hands are placed on the anterior plane of the thorax, in the centre). The chances of success increase when these methods are combined, although in order to simplify training, it is recommended to start with abdominal compressions and, if they prove to be ineffective, perform compressions with dry thrusts to the thorax. In the case of pregnant women or obese persons (where it impossible to encircle the abdomen) initially compressions with dry thrusts to the thorax should be implemented. When the victim loses consciousness, the resuscitator must immediately initiate CPR manoeuvres, and must check whether there is something blocking the victim’s mouth (removing it is this were the case) each time the airway is opened1,5.
In conscious children under 1, five hits should be given to the back -between the scapulae- alternating with 5 compressions with dry thrusts to the thorax until the child has expelled the foreign body or loses consciousness. The Heimlich manoeuvre is not recommended in such cases, owing to the possibility of damaging the child’s liver at this age. If the child loses consciousness, CPR procedures must be initiated, noting whether there is anything in the child’s mouth (removing it only if it is seen) each time the airway is opened6,7.
This was introduced into clinical practice by Henry Heimlich in 19748-12, and it has saved the lives of more than 100,000 North Americans, among which Ronald Reagan, Elizabeth Taylor, Goldie Hawn, Walter Mathau, Kack Lemmon and Cher could be mentioned13.
It is considered to be the procedure that most lives has saved throughout the world and has served as a basis for the creation of the Heimlich Institute, whose motto is Benefiting Humankind by Health and Peace. However, this manoeuvre is not completely free of risks and many published articles have cast doubt on its effectiveness (above all in comparison with other techniques) and have highlighted its complications14-20. The manoeuvres for resolving a FBAO are not recommended in drowning victims since they are unnecessary and may cause lesions, vomiting, or aspiration, and CPR should be delayed.
Currently, this manoeuvre is known to many thanks to programs for training in life support, both for healthcare workers and those who are not, and especially in first interveners (security forces, fire personnel, and especially in the home and school environment). These training programs started in the USA (including those proposed by Heimlich himself) and have rapidly spread throughout the world, although there are still many who should learn this and other techniques, above all those of basic life support. One very positive aspect is the interest of health authorities in fostering knowledge about the issues of health professionals, although much remains to be done (at least in Spain) to vehicle such information to the rest of the population
Faced with a situation of severe FBAO, the Heimlich manoeuvre, among others, is indicated in the following circumstances:
To perform the manoeuvres on a conscious person, sitting or standing, the resuscitator stands behind the victim and proceeds thus:
On other occasions the manoeuvre is done with the victim lying down, in the following way:
This manoeuvre is universally known and is a celebrity in its own right, and it has appeared in many artistic, cultural and recreational manifestations, such as comics, films, TV series, dictionaries and encyclopaedias and even in some TV shows.
Among the commercial films in which it appears are:
Christine (1983), by John Carpenter, This film is based on the homonymous best seller by Stephen King. This terror/thriller movie stars Christine, a red and white’58 Plymouth Fury made in Detroit, whose chassis harbours a malignant entity that finishes off anybody who crosses its path or bothers it in some way. The first to undergo its malevolent intentions was one of the workers on the construction line who dared to smoke inside the car. Later, almost abandoned and beginning to fall apart, the car seduces Arnie Cunningham (Keith Gordon), a 17 year-old who is somewhat overprotected by his parents, into acquiring and repairing it. As from that moment, the car demands absolute and unconditional devotion from Arnie and begins to make victims of any third party trying to get between the two of them. It is thus that when Arnie begins a relationship with Leigh (Alexandra Paul), the evil car induces an FBAO in her while she is eating inside it. It locks the doors and the seconds drag on forever for the unfortunate choking Leigh until she manages to open the door of her seat and someone manages to get her out of the car and performs the Heimlich manoeuvre on her with a perfect and highly effective technique (Figure 4).
Delirious (1991), by Tom Mankiewecz, is a fantasy comedy. In it, Jack Gable (John Candy) a soap-opera writer, undergoes a head injury and recovers consciousness in the set where his current soap-opera is taking place (Beyond our Dreams). After his initial surprise, he discovers that he can control what is going on around him; what he writes on his typewriter actually occurs and changes the story. He decides to take advantage of these circumstances and make a play for Laura Claybourne, (Emma Samms), the heroine of his soap opera who in reality is Rachel Hedison, with whom he is in love. After a series of events involving Laura’s family and boyfriend, whose underlying story involves a drug for obesity, he ends up falling for Janet Dubois (Muriel Hemingway), a nice girl and daughter of the defunct discoverer of the drug, who in real life is Louise, a young women he met shortly before his injury. Jack performs the Heimlich manoeuvre twice. The first occasion is at a party offered by Laura’s father. One of the guests chokes and Laura’s boyfriend, who is a surgeon, is unable to perform the procedure correctly, but Jack does manage to solve the problem The second time happens almost at the end of the film, when Jack is arguing with the series producers, Lour and Arlene Sherwood (Jerry Orbach and Renee Taylor), about the characteristics that the character of Janet should have. While Arlene is eating a sandwich she has an FBAO, which Jack uses to blackmail them, demanding the characteristics he wants in exchange for performing the Heimlich manoeuvre on Arlene, which he does only once and highly efficiently (Figure 5).
What about Bob? (1991), by Frank Oz. This is a psychiatric comedy in which the patient, Bob Wiley (Bill Murray), ends up driving his own psychiatrist Leo Marvin (Richard Dreyfuss) mad. Leo has an episode of FBAO and Bob does the Heimlich manoeuvre in a hilarious scene in which he even jumps up and down on him. Incredible as it might appear Leo ends up expelling the foreign body (Figure 6).
Groundhog Day (1992), by Harold Ramis. This fantasy and romantic comedy stars Phil (Bill Murray), a grumpy unfriendly weatherman for a TV channel. As in every year, he must cover the information relating to Groundhog Day, a festivity held in Punxtawnwey, a small village in Pennsylvania, (USA). After gathering the information, on their way home Phil and his team are surprised by a snow storm that obliges them to return to the town and spend the night there. Next morning, he realises that the clock radio is giving him the same information as on the day before and as from that moment he begins to relive all the experiences that happened on the previous day. This situation is repeated day after day and leads him to continuously try to change events, which creates ingenious and amusing situations and eventually leads to a change in Phil’s values. One of the repeated scenes takes place in a restaurant in the town. There, one of the diners is eating a steak. A large lump of meat causes an FBAO, which Phil solves majestically with the Heimlich manoeuvre (we know that since the fact was repeated over and over, he had learned it well and performed it with technical perfection) (Figure 7).
Mrs Doubtfire (1993), by Chris Columbus. This is a comedy in which Daniel Hillard (Robbie Williams) takes the place of a middle-aged woman -Mrs Doubtfire- in order to gain access to his children after an acrimonious divorce and the refusal of the judge to grant him custody. One frantic and ridiculous scene takes place at a restaurant visited by Daniel’s ex-wife Miranda (Sally Field), her current partner, Stu (Pierce Brosnan), their children, and Daniel himself (dressed as Mrs Doubtfire). “Mrs Doubtfire” seasons Stu’s food with something “she” knows he is allergic to. When Stu swallows the food its sticks in his windpipe, leading to an FBAO. The alarm is given and everybody starts shouting. Stu tries to perform the Heimlich manoeuvre on himself, but to no avail. “Mrs Doubtfire” hesitates about helping him but eventually decides to aid his usurper. He does the Heimlich manoeuvre on several occasions (correctly so) and even lifts up his victim, causing surprise among the witnesses. At the end of the scene, both fall to the ground and the foreign body shoots out of the victim’s mouth. But the scene does not end on a good note, because with all her efforts “Mrs Doubtfire’s” make-up runs and Daniel is discovered for who he is (Figure 8).
That Old Feeling (1997), by Carl Reiner. This romantic comedy portrays the reunion between a divorced couple, who still hate each other after 14 years’ separation, on the occasion of their daughter’s wedding. She is Lilly Leonard (Bette Midler), a movie actress, and he is Dan de Mora (Dennis Fatina), a journalist. The daughter, Molly de Mora (Paula Marshall), aware of the mutual loathing between her parents, is fearful about the consequences of the meeting even though both of them have promised to behave as befits the occasion. As expected, of course, the first result of the meeting is a shouting match, which –surprisingly- gives way to the rekindling of feelings and leads to a passionate affaire between the two ex-spouses. This causes no end of problems. During the credits, we see Molly choke on the ring that her fiancé has put in the cake. To stop her from choking further, a waiter performs the Heimlich manoeuvre (Figure 9); the ring flies out and hits her fiancé on the nose.
Miss Congeniality (2000), by Donald Petrie. A serial bomber (“The Citizen”) threatens the celebration of a Miss US pageant. On doing a computer search for an FBI agent who can be infiltrated into the pageant, the police realise that it can only be Gracie Hart (Sandra Bullock), although she will need a “handler”, Victor Melling (Michael Caine), to train her how to change her style and smooth out her rough and unfeminine ways. It is a great opportunity for Hart, who is awaiting trial for not having followed her superiors’ orders in an early police operation. In this operation, with which the film begins, there is a police raid in which we see one of the “bad guys” eating peanuts. He suffers an FBAO and, disobeying orders, agent Hart performs the Heimlich manoeuvre on him (this is effective, although the technique is poor), but after expelling the foreign body the bad guy takes Hart hostage and begins his flight, in which an agent is wounded (Figure 10).
Black Knight (2001), by Gil Junger. This is a fantastical adventure comedy, undoubtedly a tribute to A Connecticut Yankee in King Arthur's Court. Jamal “Sky” Walter (Martin Lawrence) works dejectedly in a mediaeval theme park -Medieval World- , which, to his frustration is threatened by the construction of a similar park close-by. After falling into a disgusting moat of the park in an attempt to retrieve a medallion, he finds himself in 14th Century England (1328) in the kingdom of the usurper King Leo (Kevin Conway). He presents himself to the usurper as a messenger of the Duke of Normandy, who wishes to establish an alliance with Leo through his daughter. He meets Victoria (Marsha Thomanson), a young woman who is head of the opposition faction in the castle; that is, followers of the legitimate queen. In one of the amorous adventures within the Court, he is found “in fraganti” with the King’s daughter. The King realises that not only has the upstart stained his honour and that of his daughter but also that this action will prevent the marriage with the Duke of Normandy. Just as he is about to be punished for his deeds, Jamal tries to make the village believe that he is a sorcerer, and indeed he manages this because just as he is about to be executed, the executioner chokes on a piece of apple. This is the punishment, and the irony is that he rescues the executioner by performing the Heimlich manoeuvre, albeit clumsily. The village people understand that both the problem and its resolution have been caused by enchantment (Figure 11).
Heartbreakers (2001), by David Mirkin, is a soap comedy in which two beautiful women -mother and daughter- devote themselves in tandem to scamming men who fall into their clutches. The mother Max (Siguourney Weaver) looks for the patsies, evidently rich ones, and marries them. After the wedding to one of them, her daughter Page (Jennifer Love Hewitt) also enters into the “circle of sting”; she seduces her step father, and her mother (of course) catches them in fraganti. The succulent prize after a law suit is evidently split between the two ladies. In a Café Page chokes on a Martini olive while she is looking at a man she believes has fallen into her trap but who is paying no attention to her even when she is signalling that she is choking (Figure 12). In the end she is saved by a waiter who performs the Heimlich manoeuvre on her.
Mr. Deeds (2002), by Steven Brill, is a new version of a story that has appeared many times in the cinema; that of a good-natured country boy who inherits an enormous fortune from an unknown relative whom the partners of that defunct relative try to trick into giving back the cash.. The story features a journalist who pretends to be a school nurse in order to exploit the story of the rich young man and who in these circumstances has to apply the Heimlich manoeuvre to save a choking child (Figure 13).
Slackers (2002), by Dewey Nicks. In this comedy, Dave Goodman (Devon Sawa), Sam Schechter (Jason Segel) and Jeff Davis (Michael Marrona), who have fraudulently passed all their exams at the University, are about to graduate; they only have to pass their final exams, which they are also preparing to cheat in. However, they have not foreseen that something would stop them from doing this. In a restaurant Sam fakes an FBAO and when Dave does the Heimlich manoeuvre a piece of food flies out of his mouth and hits a man in the forehead (Figure 14).
Duplex (2003), by Danny DeVito. This is a dark comedy very much in the style of DeVito. Akex Rose (Ben Stiller) and Nancy Kendricks (Drew Barrymore) are a happy young couple with a promising future. He is a writer and has published a novel, and she works for a magazine. Their happiness is only marred by the fact that they don’t have a decent apartment. Luck seems to smile upon them when they find a large duplex in Brooklyn. There is only one slight problem: the upper part is occupied by a certain Ms. Connelly (Eileen Essen), who is nearly a hundred years old. In view of her age, it appears that the woman is unlikely to last long, so they buy the duplex and the “slight” little problem begins to acquire enormous proportions as the elderly lady begins to make their life impossible. The film is replete with comic situations and often razor-sharp dialogues. One special scene is when Ms. Connelly suffers an FBAO while eating a sweet and Alex tries to help her. He picks her up out of her chair and begins to perform the Heimlich manoeuvre on her (Figure 15), with more enthusiasm than skill, as can be seen from the clearly incorrect positioning of his hands, whose fingers are interlaced. Nevertheless, in the end he manages to get a foreign body to spurt out of the old lady’s mouth, from where it splashes directly onto Nancy’s face. Surprised by the success of the manoeuvre, Alex drops the old lady onto the floor, where she enters cardiorespiratory arrest, so he starts basic cardiopulmonary resuscitation techniques -or to follow today’s jargon- Basic Life Support. This is a short but extremely funny scene in which, although with a highly deficient technique, the couple incredibly do manage to save the victim (the best part is Alex as a resuscitator offering mouth to mouth).
Deuce Bigalow: European Gigolo (2005), by Mike Bigelow). Just from the title we can see that this is a comedy. Deuce Bigalow (Rob Schneider), an ingenuous and kind-hearted fish-tank cleaner, thought that his career as a gigolo had ended until T.J.Hicks (Eddie Griffin), his former pimp, forces him to come back when he (Hicks) becomes involved in the murders of some of the best gigolos in Europe. He wants Deuce to prove his innocence, but along the way Deuce becomes entangled in the powerful European Union of Male Prostitutes, which serves some really weird clients. In the film we see two simultaneous examples of the Heimlich manoeuvre Deuce is having dinner with a gigolo who suffers an FBAO without Deuce realising it. Hicks appear and jumps onto the stomach of the poor chocking man who is on the floor. The offending material flies out into the mouth of another diner, who in turn suffers an FBAO, which Deuce fixes with an orthodox Heimlich manoeuvre (Figure 16).
Trust the Man (2005), by Bart Freundlich. This is a romantic comedy whose action takes place in Manhattan, and it narrates the adventures of two couples in attempting to attain some kind of stability. One of the couples is formed by Rebecca (Julianne Moore), a theatre actress, and her husband Rom (David Duchovny), a sex addict who is more interested in looking after his two children than in his relationship with his partner. The other couple is made up of Tobey, Rebecca’s brother (Billy Crudup), who is living off his rents, and his partner Elaine (Maggie Gyllenhaal), who wants to get married, have children, and write a story book. One night, after supper, Rebecca chokes on a piece of cake and suffers an FBAO. She is saved by the Heimlich manoeuvre her husband performs on her (Figure 17).
Choking Man (2006), by Steve Barron. The tile of this film is a faithful reflection of the choking of the main character Jorge (Octavio Gómez Berríos), an illegal Ecuadorian immigrant in the States. Jorge survives by washing dishes in a restaurant in Queens (NY), the county with the greatest ethnic diversity in the USA. His problem is both social and employment-related. The society in which he lives is completely foreign to him and the owner and manager of the restaurant where he works bully him unceasingly. On top of all this, in front of where he slaves away Jorge has a poster telling how to perform the Heimlich manoeuvre on someone who is choking. He studies this assiduously every day (Figure 18). The laws of NY make all restaurants have this poster. At the end of the film Jorge has the opportunity to put into practice what he has learned from the poster.
The Pink Panther (2006), by Shawn Levy. This is a remake of the film of the same name from 1963, directed by Blake Edwards and starring Peter Sellers. In this new version, Inspector Jaques Clouseau (Steve Martin) has to solve the murder of Yves Gluant (Jason Statham), the trainer of the French football squad, and the robbery of the famous diamond, the Pink Panther. Towards the end of the semi-final between France and Chine, Yves Gluant is on his way to celebrate the victory of his team when he collapses, due to a poisoned dart he receives in his neck and the ring holding the Pink Panther disappears from his finger in the ensuing fracas. The action, of course, revolves around Clouseau’s clumsiness and the desperation of Dreyfuss (Kevin Kline), his boss. In one scene, Clouseau performs the Heimlich manoeuvre on Nicole (Emily Mortimer), his assistant, who is choking on an egg. The technique is successful since the piece of egg flies out of the window and hits a passing cyclist on the head, who loses control, runs into a hotdog stall, which explodes (Figure 19).
A Scanner Darkly (2006), by Richard Linklater. This is a rotoscoped film and is a cop thriller/SciFi combination. The plot is disturbing because it’s possible. In order to protect people from drugs, the police keep tabs on them. The action takes place in Orange County in California. A man suffers an FBAO when he is eating; he tries to do the Heimlich manoeuvre on himself and eventually manages to do so with the back of a chair (Figure 20).
Victory Blizzard (2007), by Greg Carlson, is a short movie that includes the Heimlich manoeuvre in its four-minute duration.
The Messiah (2001), by Diarmuid Lawrence; produced by the BBC and based on the novel by Boris Starling. Inspector Red Metcalfe (Ken Stott) of Scotland Yard investigates a series of murders that have taken place in London and soon realises that the murderer is killing people with names and jobs similar to those of the 12 apostles. As in many TV series, be they of a health-oriented nature or not, this film portrays a scene of the Heimlich manoeuvre. Shrek said Happy Christmas to his fans with Shrek the Halls (2007), by Gary Trousdale, in which the Heimlich manoeuvre is an important element.
The History of Choking (2002) by Abel Klainbaum. This is a short film in comic key, which apart from portraying the manoeuvre includes an interview with Dr. Henry J. Heimlich (Figure 21). Eddie Izzard; Dressed to Kill (1999), by Lawrence Jordan features the show that the comic cross-dresser made in San Francisco, in which, among other aspects, the Heimlich manoeuvre is dramatised.
The scientific and documentary cinema has also addressed the manoeuvre, such as in The Heimlich Manoeuvre: How to Save a Choking Victim (1983), by James Tartan, or Don’t Choke: The Heimlich Manoeuvre DVD (2004). The Heimlich manoeuvre also forms part of the contents of films addressing first aid such as CPR: Learn how to Save a Life (1998) or BLS for Health-Care Providers (2007) (Figure 22). Some Universities have made videos about this manoeuvre that can be seen free of charge at (link). Finally, there are veterinary films about the Heimlich manoeuvre, such as K-911 Emergency First Aid Video (1996).
The Heimlich manoeuvre appears in a short but significant number of commercial films, which means that they can be used to disseminate and teach the technique, thanks to the drawing potential of this type of cinema. In this case, the simple viewing of the scene including the manoeuvre would undoubtedly be sufficient. It should be stressed that most of the films are comedies, such that to a certain extent the seriousness of FBAOs is de-dramatised. It is appropriate to emphasise this and the viewing of Christine (1983) would be suitable. On the other hand, there is an important number of documentary videos and DVDs that can be used for teaching the manoeuvre, although the attractiveness of these materials is more reduced because they tend to be only technical.
Figure 1: Universal sign of choking
Figure 2: Correct position for performing the Heimlich manoeuvre
Figure 3: Heimlich manoeuvre with the patient lying down
Figure 4: An FBAO caused by the malevolent car in Christine
Figure 5: An effective manoeuvre inDelirious
Figure 6: The patient saves his psychiatrist in What About Bob?
Figure 7: Expelling the foreign body in Groundhog Day
Figure 8: The doughty Mrs Doubtfire helps his wife's partner
Figure 9: A Walter performs the manoeuvre on Molly in That Old Feeling
Figure 10: Signs of choking in Miss Congeniality
Figure 11: The Heimlich manoeuvre performed on the executioner in Black Knight
Figure 12: Page signals that he is choking in Heartbreakers
Figure 13: The FBAO of Mr. Deeds
Figure 14: Expectation before and FBAO in Slackers (2002)
Figure 15: Alex pulls Ms. Connelly out of the chair and performs the Heimlich manoeuvre on her in Duplex
Figure 16: Heimlich manoeuvre performed by jumping on the abdomen in Deuce Bigalow: European Gigolo
Figure 17: Heimlich manoeuvre (for the third time) in Trust The Man
Figure 18: The laws of New York make all restaurants display a poster showing how the Heimlich manoeuvre should be carried out
Figure 19: The unforgettable Inspector Clauseau in action
Figure 20: The back of a chair can be sufficient to perform a Heimlich manoeuvre in A Scanner Darkly
Figure 21: Choking in a restarurant in Victory blizzard
Figure 22: The choking person puts hand to throat in The History of Choking
Figure 23: BLS for Healthcare Providers