TRANSCRIPT OF PROCEEDINGS >!

* r* 7>r~J V
NATIONAL ACADEMY OF SCIENCES

EMERGENCY AIRWAY MANAGEMENT CONFERENCE

PLENARY SESSION

Date:

June 22, 1976

Place:

Washington, D.C.

Pages 1-75

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NATIONAL ACADEMY OF SCIENCES

2
3

l4
5
EMERGENCY AIRWAY MANAGEMENT CONFERENCE

6
PLENARY SESSION

Auditorium

National Academy of Sciences

2101 Constitution Avenue N.W.

Washington,

June 22,

D.C.

1976

10
The meeting was convened pursuant to notice at 10:00 a.m.
11

Moderator,

12

Dr .

PARTICIPANTS:

13

Dr.

Dr.
Dr.

14

15

16
17

18

William Matory
Alan Goldberg
Arnold Sladen

Dr.

Peter Safar

Dr.

Don Benson

Dr.

Albert Hillberg

Dr.

Arthur Gordon

Dr.

Jerome Schofferman

Dr.

Herman Alveraz

Dr.

Andrew Poledor

Dr.

Paul Mesnick
Gabriel Tucker

Dr.
Dr.

Edward Patrick
Henry Heimlich

Dr.

T.

Dr.

Martin McLaren

Dr.

21

Dr.

Vincent Collins
Ronald Stewart

Dr.

Sam Seeley

22

Capt. John Waters

Dr. Trevor Highes
Dr. Leonard Rose

Dr.

19

20

William Matory.

23
24
25

A.

Don Michael

Dr.

John Steinhaus

Dr.

Tamarath Yolles

Dr. C.
Dr.

W.

Guildner

Stanley Weitzner

Dr.

B.

Dr.

Elliott Salenger

Raymond Fink

Page

CONTENTS

1
1

2
3

Dr.

Dr. Alan Goldberg

Boston University School of Medicine

NON-CANNULATING DEVICES FOR AIRWAY MANAGEMENT - WORKSHOP III

University of Pittsburgh School of Medicine

CANNULATING DEVICES FOR AIRWAY MANAGEMENT -

11

12

16

WORKSHOP IV

Dr. Peter Safar

University of Pittsburgh School of Medicine
37

MANUAL METHODS FOR AIRWAY MANAGEMENT - WORKSHOP I

13

Dr.

Don Benson

NRC/EMS Committee
University of Pittsburgh School of Medicine

14
15

16
17

18
19

20
21

Dr. Arnold Sladen

10

OXYGEN-POWERED BREATHING DEVICES - WORKSHOP II

William Matory

NRC/EMS Committee
Howard University College of Medicine

5
6

PRESENTATION BY:

22

23
24
25

5/22/76

IAS/EAMC
PROCEEDINGS'

DR. MATORY:

Good morning again.

This is the plenary session,

at which time we will

hear the individual reports from workshops and get the reactio
from the workshop participants.

We will have reactions and comments and questions

after each workshop, after which we will have questions and
8

comments from the participants of the workshops,

following the

end of the full reports.

Dr. Albert Hillberg,

10
11

National Research Council, would like

12

DR.

13

HILLBERG:

Thank you,

to make an announcement.

Dr.

Matory.

just want to remind all of the participants and

14

guests and visitors

15

conference has been.

16

Committee,

17

Life Sciences,

18

mended procedures

19

and professional personnel.

of

to this conference what the purpose of thi

And that is

to provide advice to the EMS

the Division of Medical

Sciences,

Assembly of

in its task to prepare a report concerning recoi

for emergency airway management by both lay

Proceedings of this conference in the sense of a

20

a professional associate of the

21

literal presentation of all deliberations will probably not be

22

published.

23

tions by the EMS Committee.

24
25

Instead, these will form the basis of the recommenda

The Emergency Medical Services Committee will

recommend what may be needed in

also

the sense of continuing resear

and study in the

field.

The final report, after deliberations by the Emergenc^

Medical

Services Committee,

will be published in an appropriat

widely distributed medical journal and may also be published as

a separate report of the Academy.

This

to be determined.

I think you should all keep this in mind as you list

to the deliberations of the workshops.
8

sented to the Emergency Medical Services Committee

liberations .

for its de

70

Thank you.

11

DR.

12

I should reemphasize that for those interested organi

MATORY:

Thank you,

Dr.

Hillberg.

13

zations who would like to have their ideas and views utilized

14

as a part of the final report, we would like you to submit in

15

writing your suggestions to the Committee.

16

These are to be pre

The first report will be given by Dr. Alan Goldberg,

17

who was the chairman for the workshop on

18

ing Devices."

19

Dr.

Goldberg.

20

DR.

GOLDBERG:

The

first thing that we

21

change the title of our workshop,

22

more widespread,

23

"Gas-Powered Resuscitators,"

24

it would be possible for a device

I 25

"Oxygen-Powered Breath

did was

to

to make it a more generic,

more widely applicable term.

We changed it to

the thinking being that conceivabl

to be powered by air and sti]

have some oxygen for supplementing the inspired gas mixture.

We proceeded to a definition of these devices, as

follows:

which may provide an oxygen-enriched gas mixture in an emergency

situation and limited to short-term use.

A means of mechanically ventilating an apneic person

And, secondly, may provide an enriched oxygen mixture

5
6

to a spontaneously breathing patient.

The types of devices we divided into two categories

7
8

for an apneic victim and for a spontaneously breathing victim.

For the apneic victim,

10

which is operator-cycled, where the control of the phases of

11

ventilation is

determined by

the operator.

And a second type under apneic victim is pressure-

12

13

cycled,

14

tion according to pressures achieved in the patient's airway.

15

first, manually triggered

meaning a unit which cycles from inspiration to exhala

For the spontaneously breathing victim,

two types:

16

First, an inhalator, which is operator-controlled and provides

17

a continuous gas

18

patient-cycled,

19

airway pressure and provides increasing flow as increasingly

20

negative pressures are applied.

flow;

and secondly,

pressure-limited.

a demand valve, which is

This is activated by negativ

21

Third,category of discussion was indications

22

Manually

23
24
25

triggered devices only for emergency resusci

tation of apneic victims; not designed

Secondly,

for use.

for chronic use.

the pressure-cycled devices should not be

used during cardiopulmonary resuscitation,

because sternal

compression results

in increased intrathoracic pressure that

terminates the inspiratory cycle before an adequate tidal voluro

has

been reached.

The inhalator should be reserved for spontaneously

breathing patients only.

And the demand valve should be reserved also

for

spontaneously breathing patients.

Fourth,

the method of operation

that that we covered was

that the operator should be able to

10

maintain proper mask fit with both hands and still be able to

11

control the operation of the device.

12

Next,

13

First, manually triggered devices.

performance criteria.

;"..!-;

The flow rate

14

as a minimum average we chose 100 liters per minute, primarily

15

based on a minimum tidal volume for an adult of 800 ML to be

16

applied in the half second upstroke between the sternal compres

17

sions.

18

as a flow rate.

19

the only aspect of

And so that calculates out to be 96 liters per minute

And we rounded that off to 100,

The inspiratory pressure the maximum allowable

20

we decided that 60 centimeters water would be a desirable figurs

21

The inspired oxygen percent we decided that a range

22

would be acceptable,

of from 50 to 100 percent,

primarily be

23

cause the feeling was that it is not always necessary or riot

24

always necessary tp provide 100 percent oxygen.

It is not neces

25

sarily better than a somewhat lower percentage.

And 100 percen

oxygen can cause some adverse effects,

such as increasing the

shunt and also because this a less stringent requirement hers"

would make it easier for manufacturers
4

gas

to provide more efficien

flow.

Ventilating frequency

a minimum capability of 12

cycles per minute.

And,

lastly,

so

that once

passively,

the patient must be permitted to exhale

the

these manually triggered devices

once the control is deactivated that the pressure does not con
10
11

On the pressure-cycled devices,

again,

the pressure

12

must be permitted to exhale passively, without any negative

13

pressure being applied to the airway,

14

of airway closure with negative pressure.

15

And

then

the panel

because of the possibilit

thought that more research

is

16

needed to determine minimum performance criteria for the pressujre-

17

cycled devices,

so we really couldn't come up with any

18

recoiranendations

for these devices.

19

tinue and the patient exhales.

For the inhalator,

flow rate a minimum of 10 liter

20

per minute.

21

teria that we could decide on.

22

Fifty-percent oxygen was

Then for

further

the demand valve,

the only performance cri

first,

the negative pres

23

sure required to initiate inspiration would be a maximum nega

24

tive pressure of minus

25

1.5

centimeters water.

The flow rate a minimum 200

liters per minute peak

inspiratory flow rate, with airway pressure not to exceed minus

5 centimeters of water during this peak flow rate.

And the positive pressure required to terminate inhal^

tion a maximum of plus

The next category was design criteria.

5
6

list of these,

reassemble the device incorrectly.

the first being that it should be impossible to

60 centimeters of water be presented to the patient.

10

words,

11

to be presented to the patient,

12

the device.

than

In other

that the line pressure of oxygen should not be permitted

in the case of some failure of

13

It shall contain a standard 15/22 millimeter fitting.

14

If the oxygen

tank empties,

a safety valve shall be

15

triggered at minus 5 centimeters of water,

16

to allow spontaneously breathing patient to breathe room air

Foreign body secondary to voraitus

17
18

20

ihall not interfere

Must supply at least one-half-hour gas capability frofn

one E cylinder in any mode or combination of modes.

All devices should be capable of functioning as eithe

21
22

to allow the patient

with the .function of the device.

19

And we have a

In no mode of failure shall a pressure greater

2 centimeters water.

inhalator or

demand valve.

Environmental conditions such as dropping,

23
24

tion,

temperature extremes,

25

this deferred until more data available*

vibra

barometric pressure advice on

And, lastly, the devices should be easily disassemble^

and cleaned and capable of being sterilized by commonly used

techniques.

DR.

MATORY:

Are

there any questions or comments

(There was no response.)

It is very clear,

Dr.

Sladen.

10

DR.

SLADEN:

Goldberg.
from the other

Dr.

Dr.

Goldberg.

Matory,

ladies

and gentlemen,

this

is a verbatim report of Workshop III without comment.

12

13

Dr.

workshop participants?

11

The charge of Workshop III was noncannulating devices

for airway management.

14

Thank you,

The following devices were

recommended

for use by

15

alied health personnel having received appropriate

16

those experts

17

recommended

18

health personnel EMT1, EMT11, respiratory-therapy technicians,

19

nurses and physicians,

in

their use and application.

for use by the lay public.

The devices discussed were

21

1.

Airways,

22

2.

Suctioning devices,

the

They have not been

Included are allied

et cetera.

20

23

training by

nasal and oral;

fixed and portable,

Throat-E-Vac;

24

3.

Masks;

25

4.

Mouth-to-mask

devices;

excluding

.5.

6.

Nasopharyngeal airways the use of these particular

Binasal pharyngeal airways.

airway devices may be preferred in awake or semiconscious pa

tients who may not tolerate an oropharyngeal airway.

of an oral airway should be attempted initially, prior to utili

ing the nasopharyngeal airway.

Insertion

The nasopharyngeal airway would prove to be of value

only in patients whose airway obstruction lies proximal to the

10

tip of the epiglottis.

These airways should be well lubricated with lidocain|e

11

12

paste or gel prior to their insertion into

13

They should not be

14

cumstances.

forced into the nasal orifice under any cir

16

kept on hand.

17

trolled by leaving the airway in place.

If nasal bleeding occurs,

should be

epistaxis may be con

It is recommended that studies relating to the length

18
19

required

20

based on body size,

21

the nasal passage.

Various lengths and sizes of these airways

15

Bag-valve mask devices;

for proper placement of the nasal pharyngeal airway,

patient age,

and weight be researched.

Oropharyngeal airway an oropharyngeal airway should

22

be used whenever

the rescuer

is

confronted with an unconscious

23

patient and is the preferred airway

24

required in the placement of the airway,

25

sertion may displace the tongue posterially and

for initial use.

Care is

because incorrect in
thus produce

airway obstruction.

Oropharyngeal airways should be available

in infant, child, and adult sizes.

Oropharyngeal airways should

not be taped or otherwise secured in place.

Either oropharyngeal or nasopharyngeal airways should

be used whenever a bag-valve mask

system is

used.

Suction apparatus we utilized the standards pub

lished in JAMA?
8

on page

lowing to the existing recommended standards:

10

"Suction Devices'

supplement to JAMA Standards on CPR.

1.

Add the

should be so sized and labeled e.g.,

12

mize the probability of exchanging connectors between pump,

13

collection bottle,

15

2.

The size of the collection bottle should be ade

quate to minimize the likelihood of overflow.

3.

ing positive pressure.

18

4.

20

color coded to mini

and tubing.

16

19

fol

The fittings and connectors on suction devices

11

14

855,

and we wish to add a rider to

A suction device should not be capable of provid

An accurate gauge should be provided to indicate

the amount of vacuum.

/ The Workshop recommends

that studies to determine the

21

physiological efficacy of existing standards on suction devices

22

be encouraged,

23

tubing and connectors and the maintenance of performance.

24

25

particularly in reference to the size of suction

Ventilation.

When total airway obstruction exists,

in spirt of appropriate positioning and attempted airway support:,

10
1

further attempts at positive pressure ventilation should be

abandoned until the nature of the obstruction has been determined

and remedied.

the case of partial airway obstruction,

tient is conscious and breathing spontaneously,

mentary

if a pa

give supple

oxygen.

If the patient is,

or becomes,

unconscious

attempt;

to directly visualize and remove the obstruction should be per

formed by appropriately personnel and this we underline.

10

11

this is not feasible,

If

ventilation may be gently assisted.

Mouth-to-mask systems.

These systems are recommended

12

for use as an initial ventilation device, which in addition may

13

be used to deliver supplemental oxygen.

14
15

16

Bag-valve mask devices.

We would like to add this

rider to the original JAMA statement:

If possible bag-valve devices should be designed so

17

as to allow the spontaneously breathing patient to breath direc tly

18

from the bag-valve device,

19

In

rather than ambient air.

Binasal nasopharyngeal airways, with 15 millimeter

20

valve adapters.

21

sonnel especially trained by individuals knowledgeable in their

I 22
23

I 24
1 25

These devices are recommended for use by per

use and application.

Further clinical evaluation of this device in mobile

intensive-care programs

is suggested.

Masks rider to the JAMA statement:

11

The mask fittings on bag-valve mask devices should be

designed to arise perpendicular to the mask itself.

In respect to the Throat-E-Vac and chokesaver,

the

consensus of the Workshop was that neither device could be reconmended, because of serious doubts as to their efficacy and safe

ty.

It is understood that the PDA plans

further evaluation of

these devices.

Finally,

8
9

the Workshop looked at a priority for the

development of performance standards

for the following devices:

10

Airways

11

Suction devices, both fixed and portable, high priority,

12

Ventilation devices,

13

valve systems,

including mouth-to-mask and bag-

high priority.

And the binasal pharyngeal airways in the prehospital

14
15

they put at low priority.

use they put at high priority.

16

Respectfully submitted.

17

Thank you.

18

DR.

19

Any comments

MATORY:

Thank you,

Dr.

Sladen.

from the Workshop participants?

20

(There was no response.)

21

Dr.

Gordon?
.

22

23
24
25

DR.

GORDON:

Dr.

Gordon,

Question,

please.

from UCLA Medical Center.

You said, that the inlet for the bag-valve mask should
arise perpendicular to the mask.

Does

this mean that the inlet

12

has to be straight up?

Or can there be an angle in it, as therk

is at present in some of the models now?

Could you clarify tha

~t

please.

DR.

SLADEN:

The mask

Can I

read it again,

please:

fitting on bag-valve mask devices

should be

designed to rise perpendicular to the mask itself.

DR.

Is

it allowable, then that.it .rise, 1

-.

perpendicular and there be an angle to the side, which now is a

feature on many of them?

10

I am thinking particularly of the lerdoff(?), which

11

has it arises perpendicular but then has a right angle to

12

the side.

13

.
DR.

SLADEN:

Well,

that was

the mask that we

felt was

14

the major problem.

15

or perpendicularly at a vertical right angle to the mask.

16

We were very unhappy with the current design.

DR.

17

18

And we felt it should come out vertically

GORDON:

Can you

I don't understand what the

problem is with the present design.

(Pause.)

19

20

GORDON:

DR.

SLADEN

(at

the blackboard):

The Workshop wanted

21

the standard 15 millimeter connector to come out perpendicular

22

to

23

to the mask.

24
25

the mask

DR.

this being a male

15

millimeter connector attach

They did want it coming out as it does at the mom lit.

GORDON:

the top of that.

But there

could

then be

a right angle at

DR.

SLADEN:

Oh, yes.

They didn't specify what hap

pens after it comes out.

DR. GORDON:
that you have on
OR.

the left?

SLADEN:

They

thought it was a problem to use.

(Pause.)

6
7

DR.

In teaching a lot of basic and advanced cardiac life

SCHOFFERMAN:

Jerome Schofferman,

from Harvard.

support, particularly advanced, we found that the design that

10

you don't like is the easiest for the bag-valve mask for non-

11

sophisticated people to use, because you can use the heel of

12

your hand to hold the mask securely to the face.

And I realize that some of you object that recom

13
14

mendation might be a little strong.

15

DR.

ALVAREZ:

16

DR.

SLADEN:

17

DR.

ALVAREZ:

18

ments.

19

to teach to the less

I disagree.

Alvarez,

I want to echo Dr.

Please.

Schofferman1s

com

We have found this to be the easier system

trained individual.

MATORY:

22

Dr.

Sladen,

23

DR.

SLADEN:

Well,

24

DR.

MATORY:

Were

25

From the participants?

21

from the University of

Can I answer the question?

DR.

20

Well, what was the objection to the one

We would take your comments

into

tion.
you had some

okay,
there

response?

you
any

other

comments?

conside

a-

14
1

(There was no response.)

DR. POLEDOR:

from the National

Restaurant Association.

You are aware of legislation which legislates devices

in the food-service operation in certain 9tates and proposed in

other States.

In effect, what the panel has said ~ that there is

7
8

no device which you would recommend for use by the lay person?

DR.

SLADEN:

No, we said,

10

available and currently in use.

11

we do not know about.

12

DR.

POLEDOR:

13

DR.

MATORY:

14

DR.

MESNICK:

15

Yes, Andrew Poledor,

Dr.

Of the two devices

that wer

There may be other devices

Thank you.
Yes?

Dr.

Paul Mesnick.

I was a member of

Sladen's committee.

16

In reference to this particular mask design,

17

viewing various bag-valve devices among the paramedics

18

in the system in Chicago,

19

criticism in terms of

20

because of the side-arm on there and the fact that joint con

21

nection was

22

tha

in re

that are

there was a significant amount of

the difficulty of utilizing the bag

frequently stressed and would come off.

And the paramedics

felt that manipulating this mask

23

was,far more difficult than manipulating those masks which came

24

off at the perpendicular angle.

25

Also,

in terms of the bag-valve devices,

I think it

15

should be stressed that these are devices which take a fair

amount of training to use correctly.

And I think looking on them as Very basic forms of

equipment is

incorrect.

I believe that too many people are

undertrained in the use.

And, as a result, we are not as

critically evaluating them as we should.

DR.

MATORY:

Thank you,

If there are no other comments, we will go

DR.

SLADEN:

Can I have

10

DR.

MATORY:

Please do.

DR.

SLADEN:

Just a comment that the use of

the hand to maintain them,

Dr.

Mesnick.

final remark?

the heel

12

of

13

will do nothing more I think than flex the head downwards and

14

thus obstruct the airway.

15

DR.

MATORY:

16

Dr.

Safar.

17

DR.

SAFAR:

the base of the mask on the chin,

Thank you.

Speaking merely as a member of

18

I hate

19

In our teaching experience it is in Pittsburgh we have

20

encountered considerable difficulty

21

patient's

22

ing down was

23

lerdoff

24

25

to disagree with Dr.

Sladen,

the audien:e,

who is one of my associates

in holding the mask to the

face with fingers only.and the heel of the hand press

far more

advantageous.

So

the

flat mask of

the

type has advantages.

You do not push the chin down,

because

chin as you are pressing down the nose.

the pull on th

The disconnection a:

16

the side-arm is a separate issue.

come apart,

upward or sideways.

DR.

Then we will move on to the next workshop report,

Dr.

Any further comment,

Dr.

Sladen?

(DR. SAFAR>^ Workshop IV considered first the sequence

of steps of emergency airway control in general.

There was unanimous or majority agreement on the

8
9

MATORY:

Safar.

following:

Diagnosing an action must go hand in hand.

10

The steps

11

recommended are,

first,

backward tilt of the head;

12

airway maneuver;

third,

upper airway clearing attempts for thos

13

recommended where

the cross-finger maneuver or finger-behind-

14

tee th maneuver to

force

15

suction and/or foreign-body clearing on the vision, where feasi

16

ble,

17

or Heimlich maneuver.
However,

19

20
21
22

second,

tripLe

the mouth open and then finger probe or

by laryngoscope and use of

18

whether the adapter goes

just shouldn't

S"

These things

forceps

and/or back blows and/

the details on the latter were left to Work

shop I.

Point four,
nasopharyngeal

step four,

insertion of oropharyngeal or

tube.

Five,

tracheal

intubation

and trachobronchial

suction

23
24

Six,

25

a.

alternatives

for tracheal intubation,

including f-

Insertion of esophageal obturator airway;

b.

Cricothyroid membrane puncture.

c.

Translaryngeal oxygen-jet insufflation.

As a seventh step,

The general comments include two more points, before

we go into specifics.
All members of the panel

^~-^r^<^r
felt strongly that the im

portance of emergency airway control in comatose patients in

general far outweighs the importance of the relatively less

10

common cases of foreign-body obstruction.

11

recommendations being considered here should consider the lattei: -

12

namely, the foreign-body problem merely in form of an appendix.

The second general comment:

13

Therefore,

the NRC

legislation should not

14

restrict the appropriate of any airway-control technique.

15

paraphrasing now:

16

in existence in California which prohibits paramedics does

17

not permit paramedics to intubate the trachea.

I ami

This was primarily because of a law reportedjly

18

Now we went into specific steps.

19

As far as clearing, comments were made on the Heimliclj

20

maneuver

and the

following recommendations made:

All agreed that in presence of trainedjnedical person-]

21

and eighth step,

broncheoscopy were discussed.

5
6

tracheotomy;

22

nel

and equipment,

direct visualization of

the upper airway by

23

laryngoscopy and the extraction of obstructing foreign body

24

should have priority overth^_Jiejjniiejimaneuver.

25

not produce an effective cough in choking patients who may have

The latter ma;

low lung volume.

Also, concern about wasting time and provocation of

regurgitation with use of the Heimlich maneuver was raised.

a person with witnessed foreign body aspiration is conscious

and can breathe,

If,

however,

he is completely obstructed and this

would usually be very rapidly an unconscious patient lay

persons should use finger probe first,

haps the Heiralich maneuver.

10

equipment,

11

scopic extraction.

then back blows,

howeyej^should proceed immediately with pharyngoThis

includes paramedics.
fail,

cricothyrotomy or trans-

13

laryngeal oxygen jet insufflation should be used.

14

ment on this later.

16

and per

Medical personnel with appropriate

If the above methods

We will com

All agreed that the^chokesaYJja: and^ Throat-E-Vac^shoul 3

15

not be used.

]7

digital probing should be avoided.

12

If

Next point on the pharyngeal tubes.

18

naso-pharyngeal tubes should continue

19

professionals, from EMTIfs upward.

20

with soft, well-lubricated tubes should be emphasized more,

21

especially for the not entirely areflexic patient.

Non-EMT

22

first responders,

triple air

23

way maneuver

instead.

24

airway,

tested on anesthetized patients, merits field

25

trials.

EPA,

like police,

to be

Use of oro- and

taught to all healti

Nasopharyngeal intubation

should be

taught the

Elamfs esophageal blocker-pharyngeal

19
1

Next, on tracheal intubation.

This was considered

"the"

it should be employed as early as possible.

during CPR,

ceptable alternative.

definitive step of emergency airway control.

During CPR

When not feasible

use of the esophageal obturator airway is an ac

All agreed that tracheal intubation should be taught

6
7

to as many health professionals as possible,

medics ambulance medical students,

nurses.

starting with para

and special-care-unit

Manikin practice to perfection is essential.

Manikins posing variable intubation problems would be

10
11

desirable.

Where practice on anesthetized patients or warm

12

cadavers is not possible, intubation experience on patients

13

under appropriate supervision in the field is recommended.

Skills

14

and knowledge of nonphysicians

in tracheal

15

intubation should be certified.

Sincerthere was concern about

16

retention of skills in tracheal intubation and other advanced

\7

life-support measures,

18

be obtained.

19

taining advanced life-support expertise,

20

trained medical and paramedical personnel, particularly those

21

engaged in ambulance work, should be limited to those essential

data on retraining requirements should

Because of the difficulty in acquiring and main

the number of highly

22

23

for

coverage

of

the

EMS

system.

Tracheal intubation equipment and training must in

24

clude, in addition\to the use of the laryngoscope, means

for

25

upper airway foreign-body extraction and division preferably

20
two types of conventional forceps,

such as the Kelly camp and

Magill forceps.
Next,

under esophageal obturator airway.

less desirable than tracheal intubation,

Although

all agreed that use of

the esophageal obturator airway has evolved as an alternative.

No hard data are available on complications with use
of
8

the esophageal obturator airway,

bility to suction the tracheobronchial

aspiration,

10

However,

ina

vomitting and
esophageal rupture,

data were presented on

the frequency

and

trained paramedics.

Some considered the use of the esophageal obturator

airway to be taught easier than

15

Thus,

that of tracheal intubation.

it might be considered

for selected EMT

's

16

instead of tracheal intubation and for paramedics in addition

17

to

18

of insertion particularly in awkward prehospital situations.

19
20
21

laryngospasm,

intubation with the obturator.

effectiveness of its use by appropriately

13
14

tree,

inhalation of pharyngeal blood,

inadvertent tracheal

11
12

such as

tracheal intubation,

because of its

greater ease and speed

The esophageal obturator airway should be used only

in apneic unconscious patients.

Some felt that the special 24-hour staffing limita

22

tions of small community hospitals may make it desirable

23

train also some nurses, who could not be

24

intubation, with use of the esophageal obturator airway.

25

Next,

to

trained in tracheal

cricothyroid membrane puncture.

Many devices

21
1

were demonstrated? none were found fully acceptable.

of cricothyroid membrane puncture by paramedics was reported.

Desirable technique modification should include the ability to

identify the cricothyroid membrane by patient,

under vision,

to use a curved cannular with a standard 15 miHi

meter adapter

for connecting ventilation devices,

with a lumen adequate for suctioning and for sustaining life

with spontaneous breathing of air.

9
10

inside diameter of about 5 millimeters

and a cannula

in

the adult.

Automatic or blind techniques for cricothyroid membra

puncture

13

should not be

used.

All medical students and physicians should be

taught

14

cricothyroid membrane puncture,

15

Paramedics should be

16

use as a last resort in intractable upper airway obstruction.

17

And its teachability for paramedics should be determined.

for instance on dogs or cadaver

taught cricothyroid membrane puncture

for

19

tion.

20

It was considered also as an alternative when intubation is not

21

possible and where compressed oxygen and the necessary equipmen

j[ 22

| 23

5.

Next, percutaneous translaryngeal oxygen jet insuffla

18

to cannulate

This would mean an outside diameter of about 6

11
12

Successfu L

This is a novel technique for oxygenation and ventilatio

are immediately available.

Ability to exhale through the upper airway must be

I 24

watched for.

I 25

membrane puncture or tracheotomy should be performed.

And if the lungs do not deflate,

cricothyroid

1.

22
1

also be taught translaryngeal oxygen jet insufflation, the former

technique for use with pocket-size equipment and breathing of

air,

appropriate connections and cannular are available.

the latter technique for use where

compressed oxygen and

Both crico thyroid merrbrane puncture and trans laryngeajL

oxygen jet insufflation merit further exploration as a high-

priority ~ as high-priority techniques in intractable acute

asphyxia with total upper airway obstruction.

10
11

12

Because of its rare use at the present time,

teach

ability studies are needed.

Tracheotomy.

This,

in contrast to cricothyroid mem

13

brane puncture,

14

care, which if at all possible should be performed in the in-

15

tubated, well-ventilated and oxygenated patient.

16

is an elective procedure

There was no agreement on

17

tracheotomy except that,

18

formed only as

19

20
21

All those taught cricothyroid membrane puncture shoul I

for long-term airway

the place of emergency

if considered at all,

it should be per

a procedure of last resort.

Tracheotomy should be taught to selected medical

students and physicians but not paramedics.
And,

finally,

bronchoscopy.

rigid-tube broncho

22

scopy may be

23

in certain instances of pharyngolaryngeal disease or severe ob

24

structive materials

25

the best method of

Open,

in

the

assuring and clearing an airway

tracheobronchial

Anesthesiologists,

tree.

otolaryngologists,

and others

23

practicing bronchoscopy should be skilled and experienced in

passing the open tube scope in the awake patient under adequate
oxygenation.

Fiberoptic bronchoscopy is more suitable for diagnosi

than for clearing of asphyxiating tracheobronchial material.
6

Thank you.

DR.

Any comments or questions

Yes,

10
11

DR.

Dr.

Safar.

for Dr.

Safar?

Doctor.

TUCKER:

Gabriel

Tucker,

Children's

Hospital,

I just want to recall for this group two comments

which were made yesterday.

One, Dr.

14

15

Thank you,

Chicago.

12
13

MATORY:

Heimlich's story of the child on whom the

Heimlich maneuver was attempted and who on whom it was not

successful, where there was a crayon in the trachea.

The use of the Heimlich maneuver in children,

17

18

one is certain that the child is obstructed, may move a foreign

19

body from the lower trachea, where there is more airway,

20

subglottic trachea, where the airway may not be adequate.

I 22

to the

And the only other comment that I would, like to make

21

unless

would be

to recall

the anatomical

drawings which were shown

23

yesterday morning,

in regard to cricothyroid membrane and its

24

blood supply,

25

and further studied that one look at the possibility of going

and to suggest that as this is further evaluated

just below the cricothyroid and just above it.

Thank you.

DR.

Is

DR.

One panel.

MATORY:
there

Thank you,

Doctor.

another comment?

PATRICK:

am Dr.

Patrick.

I was on the Number

And I think that one of the things

that we need

keep in mind that there are at least two stipulations

saving the life of an individual with an obstruction in his

airway.

11

One

is where quite sophisticated techniques,

13
14

haveapplica tioji.
an individual is trained,

The more

the better.

Another area is out in the field,

the general public,

15

the millions and millions of people who are not going to have

16

access to the pharyngoscope let alone know what it is.

17

I think we need to keep in mind that there are these

18

two separate areas.

19

maneuver is considered,

20

area where many,

21

be quite sophisticated in their training.

22

let us

say originating in the area of anesthesiology in the operating

12

for

10

to

23
24
25

And when a procedure such as the Heimlich

it must be remembered that there is an

many people will be affected and not necessarily

DR.

SLADEN:

Mr.

DR.

MATORY:

Yes?

DR.

SLADEN:

Dr.

Chairman,

on a point of or

Safer1s report was on a workshop

specifically designed on cannulating devices.

a report on cannulating devices.

And he gave such

I believe there is another

workshop that is going to report on manual methods.

DR.

MATORY:

Thank you.

Dr^JIelmlicJi?
DR.

HEIMLICH:

Dr.

Heimlich,

from Cincinnati.

just wanted to back up Dr. Tucker's statement, whicfr I

11

think is very pertinent and add the fact that it has been re

12

ported as well

13

am turning it into a good rule upside-down,

14

child down,

15

the trachea or on

16

that a small

head down,

So I

foreign body in the trachea I

the foreign body has lodged higher in

the vocal cords

and caused obstruction as wel

think his point is well taken.

17

small foreign body low down in

18

what you are

19

or turning the

recommending is

the bronchus,
it not,

Dr.

If there

is a

direct vision is
Tucker?

We have only evidence in two instances that the Heim

20

lich maneuver in adults has expelled an object that was down in

21

the trachea.

22

ther it was here or at the other meeting

23

dent on call ~ did I mention that here?

I mentioned one yesterday.

I 24

DR.

MATORY:

25

DR.

HEIMLICH:

I don't remember wheof

the medical

think so.

That was an instance of a medical

resi

26

resident able to visualize the vocal cords and then perform the
maneuver.

And another one was a girl where we had good evidence

that there was half of a lifesaver peppermint in the trachea.

But certainly in children there is this danger in the

child should not have the Heimlich maneuver if there is evi

dence that a small foreign body is low in the bronchus.

And

the child should also not be turned head down or upside down.
DR. MATORY:

Safar's report?

10

DR.

11

12

made by Dr.

13

that is that intubation either of trachea or the esophagus was

14

considered to be required as early as possible.

15

ated by the fact that it was

16

external cardiac compression may have

17

efficacy of cardiac output

18
19

Any other comments on Dr.

MICHAEL:

Don Michael,

just want to recreate one point which was

already

Safar and which I think the panel agreed on.

And

This was punctju

considered that on occasions

to be increased to get

(?).

And I think this point is worth stressing that in

tubation of one type or another is considered early.

20

DR.

21

Any other comments

22

Dr.

McLaren.

23

DR.

MCLAREN:

24

Just a reference to Dr.

25

of California.

MATORY:

Thanks,

Dr.

Dr.

Michael.

or

McLaren,

the"foreign body in the trachea.

Howard University Hospital

Tucker-who:had the kid with

27

Now we are talking retrospectively.

are going to make recommendations all we should say,

story was told by Dr.

on his own.

being very energetic,

danger really occurs.

I think if we
as

the

Tucker a kid was sitting and breathing

And when that kid was interfered with by somebody

turned the kid over.

That is when the

So the lesson to be learned is that if somebody is

breathing spontaneously or maybe just partially obstructed,

think you know a person should be a little better than

10

the adult,

11

to make dramatic modes of treatment.

to really ascertain what the problem before

12

DR.

13

Any other comments?

14

Dr.

Collins.

15

DR.

COLLINS:

16

(Laughter.)

MATORY:

it?

Thank you,

Dr.

trying

McLaren.

Thank you.

17

Or is

18

On the subject of endo tracheal intubation,

Yes.

I think

19

it is pretty clear that the training and the background,

20

tomical,

21

the teaching of this particular procedure take an extensive

22

amount of

23

i 24
25

is

ana

and the technique and the skills that are necessary in

time.

think that the first obligation that medicine has

to teach doctors

to do this.

and nurses who are

institutions,

to be able

I would say that probably of the physicians in the

28
1

audience,

that there are very few that I would want to have attempt an in

tubation on myself or anyone else

about.

On the other hand,

that I had great thoughts

therefore,

getting out into the

field and having this procedure despite the experience that

has occurred in one or two cities -- to be a technique to the

average paramedic, no matter how well trained, without practice

day by day will lose that skill rapidly.

The hazards

that are

10

going to ensue will be so far outweighing any advantages

11

it should be stopped at this

12

There should be no

or tha

time.
thrust or approval of general

13

ing of paramedics in the field of endotracheal intubation.

14

There are alternative in 99 percent of the situations

15

alternative safe ways.

16

you say,

17

procedures,

18

to

19

leaving out the anesthesiologists, or in the country

And until we do have a sufficient,

teac

as

cadre or group of physicians who can carry out these

particularly in emergency rooms, we might be able

then progress

further out into

the field.

I would be unalterably opposed at this time to any

20

approval of any kind of a statement from the National Research

21

Council or any organization giving approval to paramedics'

22

training in endotracheal intubation.

23

DR.

MATORY:

Thank you,

24

Any other comments?

25

Please

Dr.

Collins.

give your name and source.

I
1

DR.

Ronald Stewart, Director of Para

the County of Los Angeles.

tee on coming up with some very useful recommendations,

larly in regard in endotracheal intubation by paramedic person

nel.

particu

The suggestion by a previous speaker concerning the

training of paramedical personnel is interesting in that most

of these personnel would be trained very specifically and very

10

skillfully in total airway control.

11

I would like to emphasize ~ not just endotracheal intubation,

12

but total airway control.

And that is the part that

And that includes when to use it because there are

14

instances where

15

airway otherwise;

these personnel will not be able

to

control

an

they will not reach hospital alive.

So I would like to suggest that definite statements

16

for

Dr.

I would like to congratulate Dr. Safar and his comraitf-

13

STEWART:

medic Training,

29

17

be made concerning the appropriateness of training paramedical

18

personnel in endotracheal intubation at this

19

have delayed far too long.

20

DR.

MATORY:

21

Any other comments?

22

Dr.

Seeley?

23

DR.

SEELEY:

stage.

think we

Thank you very much.

I can't help but arise and talk

but it was only about eight years ago

like an

24

old man,

that in the hall!

25

of this Academy the same thing was being said about nurses

30
1

giving CPR,

that from the condemnation of the paramedic or the EMT

EMT11 ..level, the idea being decried that they interpret an

electrocardiagram.

And less time than

the

At that time the majority of the physicians in the

5
6

United States

majority of the physicians in the United States were reluctant

to even administer external cardiac compression

permit a nurse

couldn't interpret an electrocardiagram.

And the

let alone

to do it.

Now there are a number of highly trained,

10

highly

11

skilled people with repetitive experience in the paramedic,

12

classification that are doing a tremendous job,

13

whole

lot better than a lot of doctors

some of them a

I know.

(Applause from one person on the stage.)

14

And they are perfectly capable of being taught.

15

And

16

based on experience from prefield examination and retraining,

17

think it will be a disservice to make a blanket statement.

I am glad that the critic said "at this time."

18

external cardiac compression.

Now

19

"at this time" would apply in some areas, but not in those that

20

are making such rapid progress.

21

DR.

22

23

CAPTAIN WATERS:

24
25

statement.

MATORY:

am

Thank you,

Dr.

Seeley.

sorry.

Doctor,

I will make one very brief

I don1^ think that the number of doctors who

SPEAKER:

We know where you are

from,

but we don't

31
1

know your name.

CAPTAIN WATERS:

(Laughter.)

I think ~

Oh,

John Waters Jack.

I think that,

in fact,

could intubate is rather immaterial,

surgeons in a big hospital.

In

the

plenty of doctors

because you have all

And you can call anesthesiology.

field there is nobody else.

And we had better

quit comparing field treatment with hospital treatment, because

they aren't parallel.

10

DR.

11

CAPTAIN WATERS:

12

MATORY:

one other thing:

All right.

Let us quit.

DR.

MATORY:

Thank you.

14

DR.

BENSON:

Mr.

15

DR.

MATORY:

Yes.

16

DR.

BENSON:

Captain Waters,

are

two.

18

21

Chairman

there is one there

are here.

(Laughter.)

19
20

We

tell you

there aren't any doctors in the field.

13

17

And I will

DR.

HUGHES:

Trevor Hughes,

the University of North

Carolina.

I realize this is a large subject,

and we cannot cove

1 22

every instance.

2 23

in this report the pharmacological treatment of upper airway

I 24

obstruction.

I 25

in the young child.

But I wonder whether we should also consider

I arti thinking particularly of croup and epiglotti is

These are very important areas in medicine

32
1

as you know.

And I think there is evidence to suggest that recemic

epinepharin

emergency upper airway obstruction.

for example,

is a very useful treatment of

Maybe also, in this particular instance, some warning^

5
6

of interfering mechanically until everything is in the optimal

condition to apply, say, tacheostomy in operating room should bjs

thought of.

What I am suggesting is the possibility of including

9
10

a protocol for the treatment of croup and epiglottitis.

11

DR. MATORY: : Did you give your name and source, sir?

12

DR.

HUGHES:

Trevor Hughes,

DR.

MATORY:

All right,

Dr.

Safar might mention that after at his closing

13

15

16

SPEAKER:
as

MATORY:

Well, everybody knows of it,

sir.

(Laughter.)

20

There is one Dr. Patrick.

21

23

I would like to put my name in the record

DR.

19

22

thank you.

remarks.

17
18

University of North

Carolina.

14

(?),

Dr.

And in just a minute

Benson wanted to make a statement.

DR.

BENSON:

We considered the inclusion of pharma-

24

cologic management when we were drafting the guidelines

for our

25

proceedings and decided to omit it and focus on the other issues

33
that we identified.

We do agree that the pharmacologic manage

ment of airway obstruction is an element that needs

to be ad

dressed; but we arbitrarily proceeded to exclude it from these

proceedings, with the feeling that we had other, more highly

debatable issues
DR.

to consider.

HUGHES:

Unfortunately,

some people were not al

lowed to attend these extra conferences

8

wondered whether the emphasis

during the evening.

there is on arbiter

DR.

BENSON:

It may be,

10

DR.

MATORY:

Did you get your comment,

11

DR.

PATRICK:

Well,

my comment is

as a result of some of

13

to do with endotracheal intubation.

Dr.

gone on.

tried to stay current,

by going inta

the operating room and intubating.

16

tirely different situation from doing it to an unanesthetized

17

patient, say,

I do agree with the statement that the field is very

much different from the hospital.

20

als

22

g 23

\ 24
25

find that this an en

in a cardiac arrest or a respiratory arrest.

19

21

It had

15

18

And

Patrick?

slightly modified

the discussion that has

I personally have

(?).

sir.

12

14

And the training of individu

there must be given separate consideration.

I do only make a plea

that this be given careful con

sideration and training of intubation

the training of intuba

tion to paramedics be given very careful consideration, because

my own experience^Indicates that it is a difficult area.

DR.

MATORY:

You mean training and retraining?

34

DR. PATRICK:

Where do they get their experience if

they get their experience in the operating room, as a nurse

anesthetist would?

arrest well, quite different from the respiratory arrest.

That is quite different from the cardiac

DR.

MATORY:

Dr.

Safer.

Yes?

REPORTER:

(Brief pause for tape change.)

All right.

Thank you.

Please pause.

10

REPORTER:

Please continue.

11

DR.

12

Yes,

13

DR.

14

The gentleman from North Carolina may have been beyonb

MATORY:

Thank you.

Doctor?

TUCKER:

Gabriel Tucker,

Chicago,

again.

15

the scope of this,

in raising the pharmacological question.

AnJ

16

I think he raised another point which must be kept in mind.

Anp

17

that is the danger of premature or meddlesome handling of the

18

child who is

19

who may well be made totally obstructed by premature manipula

20

tion.

getting by and who is not totally obstructed and

21

DR.

22

There was

23

And then we will have Dr.

24
25

MATORY:

Thank you.

one other

Dr.
in

Tucker.

the back?

Safar to make his closing

comments.

DR.

ROSE:

Leonard Rose,

from Portland,

Oregon,

35

We have experience of about 1,000 cases of cardiac

1
2

arrest in the field.

statement about training of paramedics in endotracheal intubation

as a matter of choice, when it is possible to do the training

and when it is accepted by the community.

to afford more strokes during CPR when

This has already been given attention in the 1973 standards tha

were published in the 1974 Supplement.

the trahcea is intubated.

It is already an ac

10

cepted physiological concept that you improve cardiac output by

11

increasing the frequency of compressions

12

trachea is intubated.

13

Thank you.

14

DR.

MATORY:

15

Dr.

Safar?

16

DR.

SAFAR:

to

80 or more when the

That is already in print.

Thank you,

sir.

I merely want to make one comment which

17

applies

18

And this concerns

19

for paramedic training and performance at the national level.

to many of the comments made on

the Workshop

IV report.

the present state of development of standards

About a year ago my associate,

20

Safar's

I would also concerning the question of being able

And I would like to support Dr.

Dr.

Caroline

(?),

re

21

ceived a contract from the Department of Transportation to com

22

plete a document including a training mechanism.

23

were spelled out;

24

almost,

25

the testing was spelled out.

The objectives

And a textbook,

you may call it, was written for paramedics training.

This

includes,

obviously,

most of the airway control

36
1

techniques mentioned certainly tracheal intubation.

includes

catacholamene aerosol

croup ~

to be used under radio command or direct command of

physicians.

therapy for,

The DOT paramedics package,

for instance,

then, will incorporate

most of what has been recommended here.

ahead of these events.

one of the roles of the NRC,

inventing the wheel every time we have another meeting like

10

And we have

Actually,

to be careful.

it has been
And that is

to make sure that we are not re

this.

11

There are many events parallel with this one,

going

12

on at the national level.

13

to defend the recommendations also spelled out in the DOT docu

14

ment of Dr.

15

emergency critical experienced physician director,

16

vanced life support must be an ordered or moment-to-moment

17

directed by physician command.

18

(?)

It also

Caroline,

At the local level it will be crucia

that all ambulance services must have an

When we go into the techniques,

that all ad

there we should be

19

very liberal.

Anything a paramedic can learn,

20

mitted to do.

But when we go into judgment when he should use

21

What,

22

be very,

23

1*4
25

there must be physician command.

he should be per

And the training has

to

very controlled.

So I am in a way very liberal about the paramedics.

And the national scene I

think reflects

they'are doing there is

this

attitude,

because

just nothing I don't think I agrei

in many aspects with Dr. Collins.

2

the attitude that only the anesthetist can intubate the trachea

And it is very important to make sure that this physi

cian command is being set up, because we now at the moment have

paramedics running wild all around the country,

medicine without a license.

really practicing

DR.

The next report will be from Workshop I.

Dr.

11

MATORY:

Benson.

Thank you,

Dr.

Safar.

^.

. BENSQg:( Workshop/I Was to consider the issue of

10

manual methods

for airway control.

Workshop I worked way into the night,

12

actually the

13

wee hours of this morning, discussing and debating many of the

14

issues surrounding the manual techniques

15

airway.

16

at the moment finalized I do not have a typewritten copy to

17

read to you.

18

But the events have s ^j

for controlling the

And because our report was really not is,

I would like to go through some of our thoughts

19

present them as matters of information.

20

representatives of the panel are here.

21

ments and clarification of points that I may make*

I 22

I 23

in fact,

and

And a number of the

And I invite their com

We began our approach to the question of manual methojds

for-airway control by taking the cardiopulmonary standards

as

I 24

published in the JAMA Supplement,

1 25

And'reviewing the section on basic life support pertaining to

that we are all

familiar with

38

artificial ventilation, our first concern was the past teaching

of the primary oro-control maneuver being head tilt,

There was a great deal of discussion about whether or not this

has been borne out by history as an effective,

for providing primary airway control.

safe technique

While there is information that gives us concern abou

the continued application of this technique as a first step, we

felt that ve cannot recommend abandonment of the technique as a

first step at the present time.

We do, however, recommend that the need for gentlenesb

10
11

be stressed when one is

teaching and practicing the technique o

12

head tilt,

a primary airway-control maneuver.

13

There are reports of cervical

14

ing the head with aggressive

15

ness in performing this maneuver must be emphasized.

16

neck lift.

neck lift as

spine injury following a maneuver

force.

And so the need for gentle

Secondly, we would like to see added to the existing

17

standards an auxiliary maneuver which we refer to as

18

This maneuver is useful in providing airway patency in the un-

19

scious patient who is breathing spontaneously.

20

which ^nany of us anesthesiologistsjuse daily in our practice anl

21

almost at a subliminal level.

22

the fact that

23

more effective

24

unconscious but breathing spontaneously.

25

It is

"chin lift

a maneuve

And we have some data to support

this maneuver i.e.,

head tilt,

chin lift

is

than alternative maneuvers in the patient who is

Secondly,

the maneuver of chin lift provides additional

39
1

support for getting airway patency in a patient with dentures.

It gives you an additional method for securing the dentures

the chin.

standards

And so we propose that this maneuver be added

for

to the

these instances.

With regard to the assessment of spontaneous ventila

tion in the patient who is unconscious,

the American Heart Association is

spontaneous ventilation be detected by "look,

Look for the chest to rise and fall;

10

during exhalation;

11

cheek.

12

the current practice of

to teach that breathing or

feel,

listen."

listen for the air escaping

and feel for the flow of air against your

These items are taught widely.

And I am sure most of

13

us

14

Association program.

15

standards.

16

one can challenge whether or not these are standards.

17

to say,

teach

them here.

And they are a part of the American Heart

Yet they are not mentioned in the CPR

And we recommend that they be included,

this

18

in

technique look,

The fact is that,

19

is not mentioned,

20

is

21

advance by including that.

22

there.

feel,

listen

is

even though
That is

a standard.

since it is so widely used and it

many questions are generated regarding why it

And we feel that questions that could be answered in

(Pause.)

23

We

felt that there should be an explanatory note in

24

the standards regarding the initial ventilation maneuver which

25

is

described as

four quick

full breaths,

without allowing time

40
1

for full deflation between breaths.

that this statement leads to a lot of questions.

that a statement be inserted into the standards at that point

answering why is this done?

Now,

experience has showx

And we propos

the vast bulk of our time yesterday afternoon anil

yesterday evening and into the hours of this morning were spent

on the issue of foreign-body airway obstruction.

most of us or recognized that this, if one^ views the universal

of obstructed airways of foreign-body airway obstruction,

I think that

10

specifically food inhalation represents a relatively small

11

percentage of

12

those airways.

Nonetheless, we were all concerned with the problem

13

of foreign-body airway obstruction,

14

percentage it represents.

15

regardless of what small

The fact is we have new maneuvers that have been pro

16

posed and new devices which our panel didn't (?)

17

maneuvers which have been proposed as a remedy for the problem

18

of

discuss new

foreign-body airway obstruction.

The panel really spent a lot ofagonizing hours de

19

Again,

20

bating,

discussing,

the data that exist. the information that

21

exists

22

parallel subjects

23

the^ast^two centuries and tried to come up with a consensus

24

of opinion on exactly what position we should occupy with regard

25

to the new maneuvers,

fche_jij,sfcoric.al_data and precedents

the Academy and others

have

that relate to
dealt with over

specifically the artificial cough maneuver

41

And I can say,

2

Two statements__were generated by the committee, by th

panel.

essence, what they say is that the present data thatjie_Jiave

available indicates that an artificial-cough maneuver appears tb

be of value in cases of foreign-body airway obstruction, and tha

the specific role this procedure plays

patients must be defined.

They are relatively close in their intent,

I think.

In

in the management of theje

Now, one of our statements takes a rather generic

10
11

of how that role can be defined.

12

specific view.

13

reads as

And the other

And I will read both of those.

takes a rather

The first one

follows:

On the basis of the data presented,

14

an artificial-

15

cough_maneuver, manual_body_ thrust,

16

appears

17

of foreign bodies

18

tinue to be employed on a steady basis, employing the methodology

19

of the interim Red Cross manual entitled "First Aid for Foreign

20

jody Obstruction of the Airway."

22

23

abdominal,

or

chest thrust

to be of value in saving of life in cases of lodgement

in the oropJiarynx-Qrlarynx and should con-

Now that is what I consider the generic or broad-in-

21

that we really were not

able to obtain a uniyeseaiopinion on this matter.

as chairman,

scope statement.
>

The^more narrow statement\?ays as follows:

On the basis of the present evidence,

the Heiralich

24

maneuver alone or\in combination with other procedures appears

25

to be the most effective maneuver without ^adiunctive equipment

42
1

for sayingthe life of a person choking on food or other foreigji

matter.

as chairman

of this panel,

on the specific role, on the specific techniques for^jjnplnementaf

tion, on the specific location of the procedure and sequence.

I think that the only conclusion that I,

can draw is that there is no unanimity of opinio l

think

that we are all

agreed that all of the steps

that have been proposed may well have a place in the management

of foreign-body airway obstruction.

10

tion of each of these steps,

11

further information.

12

And

that,

13

DR.

MATORY:

14

SPEAKER:

Mr.

In the specific implementa

we be left to the accumulation of

Chairman,

is my report.

Any comments on Dr.

Benson's report?

Could he repeat the last statement he read,

15

about the relationship of the artificial-cough maneuvers

16

presence or the absence of adjunctive equipment?

17

DR.

MATORY:

18

DR. BENSON:

Dr.

in the

d-

Benson?

Mr. Chairman, with your^permission,

19

would like to read both statements.

20

fer not to read one independently of the other,

21

the mistaken impressioii all right.

22

DR.

MATORY:

Read both

23

DR.

BENSON:

Okay.

24

The first statement reads

25

On

I would not

I would pre

lest people get

May I read both statement?

statements.

as

follows:

the basis of data presented,

an artificial-cough

43
1

maneuver parentheses manual body

chest thrusts close parentheses ~

the saving of life in cases of lodgement of foreign bodies in

the oropharynx or

a steady basis,

Cross manual entitled "First Aid for Foreign Body Obstruction

of the Airway."

8
9

or

to be of value in

employing the methodology of the interim Red

The second statement

follows:

10

On the basis of the present evidence,

the Heimlich

11

maneuver alone or in combination with other procedures appears

12

to be the most effective maneuver without adjunctive equipment

13

for saving the life of a person choking on food or other foreigi

14

matter correction:

15

DR.

MATORY:

other foreign objects.

These,

as you understand,

Dr.

Benson

16

you might repeat that these are the two statements which are

17

being presented from the committee right?

18

DR.

BENSON:

Yes,

one of them yes,

19

One of them represents a majority opinion,

20

sents a minority opinionr

21

appears

abdominal,

larynx and should continue to be employed on

That is the first statement.

reads as

thrusts,

But I submit,

really,

that is

correct

and the other repre

that inajorijiy/minority is not

I 22

the issue.

f 23

universal conclusions can we draw from the proceedings of this

I 24

panel.

I 25

The issue is,

What was our what was

the what

And I think I have summarized that.

We can draw the conclusion that the artificial-cough

44
i

manem

none of the techniques proposed have been condemned.

draw the conclusion that the data available do not satisfy the

assembled scientists'

the role of these individuals of these maneuvers^.

But

they do not satisfy all the members of the panel.

DR.

Did that answer you?

MATORY:

Thank you.

10

All right,

11

Dr.

Heimlich?

12

DR.

HEIMLICH:

thank you.

Dr.

Matory,

Iwoader whether the chair

man and I were at^the same meeting.

I think maybe this might tie in with the suggestion

14
15

that was made before that the meetings

16

open to the public.

17

have the people who attended and were not part of the panel not

18

present.

20

should have been left

And perhaps it was a little arbitrary to

I think the other members of the panel here will

19

We can

curiosity and need to know specifically

13

We can draw the conclusion tha

They may satisfy specific member^ or thejjanel.

well have benefit.

surely want to speak

to

21

DR.

BENSON:

22

DRi

HEIMLICH:

this.

Mr.

Chairman

The fact of the matter is

that there

23

was a vote taken.

And the statement "on the basis of present

24

evidence,

25

other procedures appears to be the most effective method withoi:

the ,Heimlich maneuver alone or in combination with

45

adjunctive equipment for saving the life of a person choking on

food or other foreign objects11 the vote was 6 members

with the chairman voting with the minority,

lieve the chairman should be voting.

to 2,

though I don't be

Six members to two, plus

the chairman.
6

(DR.

DR.

Mr.

HEIMLICH:

Chairman_j--

Now it was

agreed that in

the statemen

that this vote would be recorded and presented.

The other statement was to have been presented by one

10

of the minority members who made statements about data being

11

presented,

but had none of his own.

12

DR.

MATORY:

13

DR.

HEIMLICH:

14

DR.

MATORY:

DR.

HEIMLICH:

DR.

MATORY:

15

have

17
18
19

All right,

Dr.

Furthermore

Dr.

Heimlich Dr.

Heimlich,

let me

--

16

BENSON;

Well,

if I may just continue with the

report

I want to

I will let you continue.

just want to make a statement ~

20

DR.

HEIMLICH:

21

DR.

MATORY:

22

DR.

HEIMLICH:

23

DR.

MATORY:

Yes.

Right now.

'

Yes.

And the statement I would like

to make

24

is to remind all present that the report that was given was the

25

report of the committee as a whole.

And I don't want us in the

46
preliminary session to get in the situation in which we go
through again individual statements or individual proponents of
each of the ideas.

And what I would like to do

is

like to remind the

audience that the report as given indicates,

was not a full or universal agreement.

And I

one,

that there

think that the

chairman has mentioned that there was a majority which supported

8

the statement that you just gave and that there was a minority

which supported a statement not as direct.

10

And I think that that and you have stated -.- you

11

statement has

12

just want us not to get into that.

13

DR.

agreed with the chairman's presentation.

HEIMLICH:

And I

I would like you to know that the i

14

was agreed by everyone present J^ha.t the vote would be taken and

15

so reported

16

that it would just be a majority report.

as

to 2 plus

17

DR.

BENSON:

18

DR.

HEIMLICH:

Mr.

the chairman.

It was not agreej

Chairman

Furthermore,

there were other distinct

19

and specific measures adopted again,

by the same percentage.

20

It was adopted by this majority of 6

21

the sequence for treating the choking victim.who,, where_choking

22

is

23

would be the Heimlich maneuver,

to 2 plus the chairman.

followed by b

a further agreed thafein

s.

the supine position,

it s known that the victim is a choking victim, the~supine~

if

47

position would be performed astride the victim by the rescuer.

Now this
It was

written down,

further agreed that in

to be reported today.
the unconscious victim

of unknown cause the first step would be mouth-to-mouth.

obstruction were detected,

If

the rescuer then would proceed with

in the supine position astride the victim or alongside the

victim to perform the Heimlich maneuver and that the advantages
8

and disadvantages of each method -r- which were outlined and

written down,

10

to be adopted.

Now I don't know what thewhole day was spent on,

11

this report is not going to be given in full.

12

members of the panel will address

themselves

13

DR.

BENSON:

Mr.

Chairman

14

DR.

MATORY:

Dr.

Benson.

15

DR.

BENSON:

For the record,

16
17

again, by the chair was

assembled people

as

sir,

if

I hope other
to it.

let me

inform the

follows:

The Chair at 12:10 this morning informed the panel

18

that the Chair felt its biases were such that a spokesman for

19

the majority opinion should be appointed to present that opinio

20

The majority opinion the majority the members of the

21

majority chosenot to appoint a spokesman to present that mat-

22

23

I would just like to make this a matter of r.ecord.

24

Now,

25

I do have the notes

Heimlich referred to.

in my files here that Dr.

And they will indeed appear as part of

48
1

our final report.

I am not prepared^to submit that the conference or th

wpjcjcshopjias accepted as a final act the adoption of these pro

cedures as we discussed them and outlined them last night.

Now there were many other people in the room.

plead with those who were there to clarify this,

their impression and their perceptions of what happened.

DR..MATORY:

DR.

I am Dr.

Patrick,

on the panel.

The I believe we have an observer here^Jjtoho will

"

say the same.

l.7T
7
-^^ ^\^><s^.^t> '.,

When the chairman asked that someone in the majority

14

Patrick.

as said by Dr. jteimlich.

12

13

PATRICK":

to clarify

My understanding of what was to be reported is precis ely

10
11

Dr.

And I

15

group present the results I believe it was Dr. Fink that saib

16

to the effect that it was the chairman's

17

at least led me to believe that

18

do it.

it was

job.

his

job and he would

19

DR.

MATORY:

20

DR.

SEELEY:~) I must say that this

Dr.

And the chairman

Seeley.

these questions

21

that have arisen are not new.to the chambers of the Council.

22

Some

23

attended or sat.

24

First,

25

of

them were more

panel would agree

spirited

them other meetings

But I would like

that

have

to make a couple of comments

t\am sure tha_t_-those--inembexs__Eresent at the

that Dr.

Heimlich has misinterpreted one very

49

important point.

Association s_enjjor_aemejvt_j it is

the obstructed upper airway and the Red Cross report on the ob

struction of tJie_upper~airHsy_^-both of which are practically

identical.

techniques.

dissension or disagreement,

validity of the abdominal thrust or chest thrust or that the

including Dr.

Heimlich,

on the

back blows or the finger probing as measures

11

ported success in a number of instances.

12

was there any dissension or any disagreement on the use of these

13

if appropriately applied.

14

in which they be applied.

Now the other

that have had re

And in no instance

There was question as

factor is

that Dr.

to the sequence!

Heimlich,

in

the dis

16

cussions,

17

scious unknown cause of apnea, the test of the the therapeutic

18

test of artificial respiration to determine if in fact there

19

is obstruction.

admitted freely to the need for testing in the uncon

And then proceed with the maneuvers.

Now the discussion of

20

At no time by the end of the meeting was there any

10

15

a position among the ~

Now in this report we had a series of maneuvers or

We discussed for two hours the American Heart

up until a quarter to 12:00 ^

21

was concerned with the validity of maneuvers,

22

on

23

what sequence in the sitting,

standing,

24

then about a quarter

the

the problems

of determining which

to 12:00

two

25 which have been read by the chairman.

should

a broaddiscussioi i

come

first or in

or supine position.

statements were

Anc

developed

It was these two statemei

ts

50
and these, two state

6-3 and the

up to

the vote

the

3-6.

The others, which had to do with the validity of tech

niques or the nonvalidity, which is unknown and the need for

research and for data-gathering all preceded the development of

a single page of statements.

It was these single-page statemen

read by the chairman that called for a raising of hands.

There was an expression among many around the table

which could well be interpreted as a consensus.

For example,

10

Dr. Heimlich agreed that the tests for patency in the supine

11

unconscious patient then you do the abdominal thrust and

12

either aside or astride.

13

was very gratified to hear Dr.

14

we put in the advantages

15

vantages and disadvantages of the astride to which he had

16

publicly disagreed on the aside position under any condition

17

until I heard him say it last night.

Heimlich agree to the aside if

and disadvantages,

as well as

the ad

If,jaer_ eight ajjdomjjaal^thrusts the maneuver is not

18
19

successful,

20

probe and back blows.

itwas also agreed that then you resort to

finger

A number of^cageshavsjgeen reported where the Heim

21

lich maneuver has

And parenthetically I must say that I

been used and then where

the back_b-lowL.Kas^

successful
24
25

Now if only one that is a hundred percent mortalit

if only one saved -- that is a hundred percent saved.

Therefor

:s

51
1

there is a place for back blows.

get what maneuvers and in what sequence?

Heimlich himself, in the reported cases of the HeimTich maneuve

reported to_him_and_jinalyzed in his office.

Nobody does,

includin

Now we are at the situation here where we have before

the nation a well-thought-out, well-digested a majority opin

ion document of the Red Cross, which is now being widely taught

and will be widely taught in the Red Cross border(?).

document has

the endorsement of

That sam

the American Heart Association.

We are at the situation that we were in in 196 3 and

10

when the question was asked of the Committee on Trauma(?),

12

timely to take up the problem of national standards for cardio-

13

pulmonary resuscitation.

14

of Jonathan Rhodes (?),

15

to awake

16

teachability,

17

gram at that time the wisdom of that decision has been well

18

borne out.

At that time, mainly due

chairman of the committee,

i:

to the wisdoi
who was elected

further experience primarily because of complications,

and the lack of uniformity pertaining to the pro

In 196JL a thoughtful,

considered,

and expert series o

20

opinions were consolidated in the conference proceedings.

21

took seven years of experience

22

which was

to

24

dividual,

25

insist that we are not as

It

justify another conference,

Now in this situation I can only conclude,

23

Is

'

11

19

But who knows how many people

that there are problems of sequence.

as an in

But that I

far along in these maneuvers

today as

52

we were in 1963, when the Academy was asked_to^ consider CPR.

therefore can only conclude that we can proceed with the_p_resen

training programs now published.

There will be mistakes made.

of teaching.

There will be problems

There will be data obtained.

But you will never

get evidence uni_L-.you bear it out or you carry it out on

a uniform basis.
8

There will be situations and if I remember

the committee, which I am not;

but I was a member of the panel

other place on the record the recommendation that we proceed no/

10

with the knowledge that we have under the presently published

11

trainings and that the NRC be prevailed upon_to setup a data-

12

gathering mechanism for successful

13

relieve upper airway obstruction,

14

time and I would guess with you that it may be at least 18

15

months or maybe two years or more before we will have sufficient

16

basic,

17

will be any better than 6-3.

and unsuccessful attempts

and that at an appropriate

fundamental data on which we can have a consensus

18

Thank you.

19

DR.

20

someone else?

21

DR.

MATORY:

HEIMLICH:

22

quoted;

23

state that as soon as I

and

Dr.

Seeley okay,

I must comment,

I believe I let me again,

24

Is

25

SPEAKER:

this on?
Yes.

to

Dr.

Heimlich,

that

can

because I have been

first let me

first

finished my statement a minute ago

53

DR.
have written

just said."

HEIMLICH:
that down.

The chairman said he said,

Yes,

"Yes,

I have written down what I have

He had written it down at the meeting,

and he was

going to present it to the committee to the committee as the

report.

DR.
down,

BENSON:

,No,

I believe I said I had written it

and it will appear as a part of our record.

DR.

HEIMLICH:

Now the statement which I read I

will read it again

The statement:

On the basis of present evidence,

the

Heimlich maneuver alone or in combination with other procedures

appears to be the most effective method without adjunctive equi

ment saving the life of a person choking on food or other forei
objects.

That,

Dr.

Seeley, was passed before we discussed the

sequence because I introduced the concept.

the sequence ingreat detail,

this.

introducing the concept of passin

The sequence was developed on the basis of this

(inaudible)

followed the Heimlich maneuver,

no evidence there is some evidence

(Here Dr.

We had discussed

because there was

for the back blows.

Heimlich moved to a better microphone.)

You further stated that there was no idea of the^re-

sults of sequencing.

On the contrary,

Dr.

Seeley,

I reported in

the morning 68 instances where back slaps or finger probes had

failed,

and other methods had failedf before the__Heimlich

54
1

maneuver.

slap or finger proBe had come

maneuver was

The only thing we didn't know was whether the back

done.

j; came here with trepidation.) And I came here in the

spirit of developing something that would be worthwhile.

with trepidation because I saw the__members oftfie panel who wer i

the same, members who had been at the Red Cross meeting.

with trepidation because I didn't see Dr.

disagreed at the Red Cross panel.

10

agenda a change, with two members

11

Cross panel who were not on the tentative agenda

12

reason.

I cam

I came

Gibbons (?)f who had

I saw from the tentative

added who had been at the Red
for whateve

13

But I did come in the spirit of cooperation and trust

14

We sat down,

15

16
17

18
19

and we modified the Red Cross last night

And we' agreed to modify it as

_____

first in the sequence before the

I have stated and as

the chairman

had written down.

I think the result is obviousJ__I no longer can remai

here and partic^pate_JjL^ajneeting -that-_-~run-.in this manner.

The Heimlich maneuver has been taught to millions and

20

millions of people

throughout the world.

21

excellent heads of departments

22

and in other countries.

23

with what it haLS-jgublished,

24

said before.

25

can offer no further suggestion.

It is

in the hands of

throughout States and local area

And if

the Red Cross wishes

to stay

my comments will stand as

I have

_I_-believe_ as_published~lt_is dangerous.

And I

I am sorry.

~~

55

DR.
fore he has

MATORY:

to

Dr.

take

Safar wanted to make a statement be

a plane.

Safar?

/'DR. SAFAR)
tried hard,

Dr.

It is unfortunate that Dr. Benson, who

and many others who have given in my opinion un

reasonable amounts of time and energy to the Heimlich-maneuver

controversy are being in a way slandered rather

'

by Dr.

his issue.

Heimlich for having spent all

this time and energy on

10

I have

three comments

11

First,

the National Research cannot and must not make

here.

12

scientific decisions and recommendations on the basis- of votes.

13

That is not how one handles scientific evidence.

14

done on the basis of anecdotal evidence.

15

the basisofemotional discussions.

Secondly,

16

than applauded

the

not be ignored.

18

explained on this basis of physics

19

like Dr.

20

published in a scientific journal.

21

mum background available

r 23

Heimlich's

It cannot be done on

facts of physics and physiology must

17

| 22

These

It cannot be

techniques,

new techniques have

and physiology.

should be prereviewed;

Then report

the data should be

And that should be as mini

for national committees

what the public should be

to be

to then decide

taught.

And thirdly ,J3r.

I 24

through his maneuver receive worldwide acclaim,

I 25

than anecdotal evidence-,

has

without more

really in a way ramrodded in my

56
1

opinion and in the opinion of many of our colleagues premature

decisions through national committees.

as a word of caution.

But we have spent too much time on this already.

I am sorry for having to be so blunt.

DR.

MATORY:

DR.

GORDONxy As a member of the panel/

Dr.

Gordon.

I would like

to make a couple of points.

First of all,

the discussion was hot and heavy.

as you can tell from the presentations,

was expressed.

11

statements required; I think there were probably nine statementk

required

In fact,

And no unanimity of opinion

10

12

I don't think there were really two

from the nine participants.

'.

'

As I recall itr

13

ther$ was no vote taken on the se

14

quencing.

15

modifying- the Red Cross manual.

16

separate motions which Dr.

18

There was no vote taken or statement made regarding

cussion on all of

There was no vote

taken on

Benson has read.

Contrary to what Dr.

17

Heimlich has

said,

there was dis

those points.

The only thing that I can recall_an official vote was

19

And I want to say this

20

taken and recorded was on the statements

21

And only on the one statement and it was recorded that there

22

was a 6

23

to

3 vote,

the

that J2r_t_Benson read.

3 including the chairman.

The other statement,

the more general

24

read but was not voted on.

25

when the second statement was read,

statement,

was

I specifically recall this because

it was my intention to

57
1

change my vote and vote for that instead.

at that late hour adjaurne4*_ And a vote wasn't taken.

So, with these things in mind, I would like to publicly

3
4

state now that my vote is for the modified statement that we di 1

not vote on las tonight,

that,

ch case it would be a 5-?to-4

for

instead of a 6-to-3.

DR.

(Pause.)

Dr.

BENSON:

Mr.

Chairman,

may I react?

Gordon and I have different perceptions of what

10

occurred.

11

panel who were there to enter their comments

12

this time.

13

And this

is why,

We voted on the

again,

I plead with members of the

statement,

into the record at

the more narrow statement

14

it was not truly a vote.

I asked for a show of hands

15

who agreed.

I asked for a show of hands of those,

16

who disagreed.

Six agreed.

Later,

17

HoweverI_th^jneeting

Three disagreed.

of those

a./.

about 10 minutes

after

as

the meeting

18

was approaching (the heights of chaos7^in( an effort to get out

19

because it (was late and hot~and uncomfortable, ^! asked for a

20

show of hands of those who agreed with the second statement.

21

And in

22

situation in the state of adjournment

23

the meeting *Dr.

24

a show of hands of\those who agreed with that other statement.

25

I think we simply have different perceptions of what

the midst of the effort,

the transient nature of

the

the effort to adjourn

Gordon_may not have been aware of my call

fo:

58
1

transpired.

DR.J4ATORY:

(DR. STEINHAUS; JL am Dr.

panel.

majority.

Steinhaus, a member of the

I might identify myself further as either one of the

I would definitely express the opinion that I

think

our chairman has expressed as well as

come of this panel most fairly and given a good opinion of it.

And I think,

as he mentioned,

10

for the second proposition,

11

to vote

13

I can remember the out

in the various

times of calling

I expressed myself as being willing

for that proposition also.

But I certainly would commend our chairman for what

12

was indeed a difficult job in a very trying situation.

14

DR.

MATORY:

15

Dr.

Collins?

16

DR.

COLLINS:

17

the chairman.

18

body of divergent opinion into a statement that we can live

19

with.

Thank you,

Dr.

Steinhaus.

I would also add my congratulations to

I think that he has brought together a large

I thought that and I would like

20

Yes?

Seeley:

to also express a

21

major congratulation to Dr.

it seems like that he is

22

always able to take a hotcake and pour some nice cool molasses

23

on it.

24

minutes ago.

25

whether we individually set up the sequence or not in our own

And I think in his statement he really did that a few

And I

think the need to get now some experience,

59
areas.

I would like to refer back to the previous part(?)

2
3

just in passing.

of Dr.

physicians

are going to be taught and utilized and the judgment of when

they are

Namely,

that the

still must remain in command of the procedures

that

to be utilized in the field.

whether it is in Los Angeles,

I can live with

in California,

or in Chicago.

Now with regard to the present report,

10

I am sorry that he has left.

With that kind of a statement,

8
9

Safar.

I would only reiterate the concluding remarks

now that it is

11

like ex post facto the crisis

12

another little simple thing and leave out Heimlich and all that

13

I think we are satisfied.

14

-.:.-

:.'.' .'.

is over let us get down to

<*.. vuci

.o

:.;

' -! ,*;.

t.

With regard to the point about establishing a natural

15

airway, if you are intending to include a statement of caution

16

in that particular sentence which talks about neck left,

17

it ought to be included, and it must be included, or some alterna

18

tive of such as

19

should be close to the occiput that is necessary just so tha

20

we will avoid the hazard with that kind of a statement and the

21

addition of your jaw thrust to chin lift whichever you wish

22

to designate it

23

indeed does represent the approach to getting an adequate airwa

then

the hand that is supposed to be under the neck

24

Thank you.

25

DR.

MATORY:

think we can live with that,

Dr.

Yolles.

because it

60
1

DR. YOLLES:

the status is of the discussion,

cerning sequencing that went on during your committee meeting.

the lengthy discussion,

con

DR. BENSON:

Could I refer that question to Dr. Seelejr?

DR.

I am really asking it in terms of the

YOLLES:

committee report.

was a vote.

quencing^under various circumstances.

I would like to ask the chairman what

You mentioned two statements

There was also some lengthy discussion about se-

Now I am not asking about the content particularly of

10

the sequencing information,

11

that body of material that was discussed,

12

mittee

13
14

and that there

DR.
Dr.

BENSON:

Seeley to respond

15

DR.

but rather:

What is

the status of

in terms of the com

With the Chair's permission,

to

SEELEY:

I would lik

that.

Yes,

I would like

to respond.

And I

16

trust that what I have to say will be accurate for the record.

17

The discussion on sequencing brought out the points,

18

first,

19

lic

that Dr.

Heimlich agreed,

for the first time and in pub-

20

DR.

21

The members of the press

MATORY:

Excuse me,

Dr.

Seeley.

that are leaving, would you

22

wait.

I want

to make

a statement.

23

DR.

SEELEY:

24

instead of the astride,

25

I won't discuss

That the aside position might be used

for example.

it any more.

I brought that up earlier

61

But when he was invited to give

the advantages

disadvantages of both of the two positions.

factory.

Now I agree with Dr.

Yolles.

and

It was very satis

But I am sure that your

report as chairman will include the discussions had on the

problems of sequence of application of maneuvers.

Briefly,

I have referred to this one of the supine

unconscious patients.

Heimlic

agreed to test first for patency by mouth-to-mouth means.

was a concesssion,

as

far as

I am concerned,

This

because he has

10

preached and condemned the Red Cross report as being dangerous

11

because of the

12

he agreed that you should test under these conditions.

13

tinig_it takes

to find that out.

Now last night

He also agreed and the general tenor was when

14

you apply the that is either the abdominal

15

the aside or the astride, position,

16

tions for either at that time,

17

the discussion now,

18

Should we^at^thajb^time,

19

the problem of the back blows^.

20

And I was very gratified that Dr.

in keeping with the indica

the discussion now,

not agreement
if this

thrust from eithe

rememb

the discussion centered on

is not successful,

entered on

We know it is inconvenient to turn the individual,

21

but you haven't been successful.

22

Heimlich agreed

23

at that time,

24

agreed that you could then turn the patient^^or^jthe victim,

25

administer the back blows and then go back and repeat.

to

So the discussion then Dr.

this jthat tfae.fJjiger__p_rQbe^ was appropriat

if eight thrusts did not accomplish jthe_end._ And

and

62

And there was no furor about this at all.

In fact,

the fact that he had concurred with the four maneuvers that are

in the Red Cross and the American Heart Association report was

exceedingly good, because he hadn't said that.

On the contrary

he said things in public that I won't quote.

Now then that called for a review of the sequencing o

the sitting or standing position.

The question then which

was not settled was that there should be consideration given to

Would it be the abdominal or chest thrust first and then the

back blows,

or should it be the other way round?

The general consensus was

that if you are going to

12

give the abdominal thrust first,

13

lack of patency of

14

that for the purposes of consistency of training

15

would probably be no objection to the abdominal

16

then

after having established the

the airway in the supine unconscious patient

that there

thrust first an<

the back blows.

But these were not and it was not appropriate that

17
18

this panel come up with final decisions

that would be the body

19

of the report.

20

panel's business is to tell the committee what the discussions

21

were,

That is not the business of the panel.

what the general tenor of

the discussions was,

The

what the

22

conclusions if any reached amounted to>

and then the recoi

23

mendations of the panel one of the most prominent events,

24

the two, was

25

quate experience and the second was that:a data-gathering:

that the review__at_an__appropriate time after ade

63
1

Does

And I am sure,

Mr.

Chairman,

that this type of this

amount of allusion to the discussion on sequencing should be a

matter of the record.

of it would be glad to edit it if you would like me to

confirm,

ceeding to the committee.

And I would stand behind the transcript

for purposes of the presentation of the panel's pro

And I hope that the press

and I hope that Dr.

Heim

10

lich or anyone else will avoid any public pronouncements or

71

any public opinions regarding discussions held at that level.

12

DR.

13

Now it is

MATORY:

Thank you,

Dr.

12:00 o'clock,

Seeley.

and I would we must get

14

the comments of the other representatives of that workshop,

15

other participants of the workshop.

16

finish up in about another 15 minutes.

17

18
19

20
21
22

that take care of it for the panel?

mechanism shouldjoe^ establishe<i_pos.thaste^.

23
24
25

Dr.

And we will hope we can

Guildner.

^GUILDNERT^ This is Dr.

Guildner.

I have only a couple of comments to make about the

controversy of the obstructed airway,

and that is that I vigor

ously support our continuing the accumulation of experience in

the field and collection of data.
be extended in

And all of our efforts shoul<

that direction.

Now due \to the late hour last night,

inadvertently overlooked.

And it is

one topic was

the last section in the

64

JAMA standards, on page 844,

And I asked my chairman this morning if it would be all right

to insert that,

this,

and it takes but a moment.

It should read,

I recommend,

that artificial ventila

tion frequently causes distension of the stomach.

most often- in children,

is most likely to occur when excessive pressures

This occurs

but it is not uncommon in adults.

inflation of the airway or if the airway is obstructed.

11

incidence of gastric distension can be minimized.

12

the beginning of this sentence

by limiting ventilation volumes

15

the adult,

17
18

sures.

23

24
25

that there is change:

to 1,000 cubic centimeters

in

Marked distension of

the stomach may be dangereus,

regurgitation and reduces

be

lung volume by ele

vation of the diaphragm.

That sentence is

in the current standards.

This one

is not:
However,

21
22

And it is at

thereby avoiding exceeding esophageal-opening pres

cause it promotes

19

20

The

The incidence of gastric distension can be minimized

14

16

It

are used for

10

13

and he encouraged me to do that.

We would be remiss in this meeting if we didn't inser

referring to gastric distension.

experience in the field has now shown

that

emptying excuse me.

N

Experience

in

the in

the

field has now shown

attempting to relieve a distended victim's

pressure over

the victim's upper abdomen is

that

stomach by manual
an almost sure way

65

to cause him to regurgitate period.

If the stomach becomes

further distended during rescue breathing, recheck and reposititttnthe airway;

exceeding

observe the rise and fall of the chest;

1,000 cubic centimeters of ventilation.

and avoid
And continue

mouth-to-mouth resuscitation without attempting to expel

stomach contents.

If stomach contents

tim's entire body on its side.

turn the vic

Elevate the lower body,

and al

low gravity to assist unless suctioning equipment is avail

able.

10

This is respectfully submitted by C.

11

The reference to this experience in the field is by

12

Alvarez and Cobb in a fantastically careful evaluation in the

13

field by both people trained as in their public training

14

program and in their paramedic and EMT program.

Guildner,

In keeping with the inclusion of things in

15

M.D.

the stan

16

dard statement or the in the NRC statement that are currently

17

being taught widely and universally,

I in addition submit this.

Also to be added in the statement,

18

do appear,

the

19

listen,

and feel,"

20

consciousness of the victim.

21

and shout"

22

and

as has been

"look,

is the initial evaluation of the level of

This has become known as

"shake

in the public basic life-support training program

should be

included here.

23

Thank you.

24

REPORTER:

25

(Brief pause

Please pause.

for tape change.)

(J5R. WEITZNER>)
Center,

Dr. Weitzner,

from the Downstate Medic

icil

in Brooklyn.

I have one observation I would like to make.

not on

the panel on discussion.

But I would like

I was

Now I was on another panel.

to make the observation that throughout this

entire proceeding I have not seen any medical or scientific dat

supporting or not supporting or condemning the Heimlich maneuye

8
9

Seeley,

think Dr.

perhaps unintentionally outlined one of the difficultie

in the collection of this data when,

11

and his

12

"condemned,"

13

emotional difficulties

14

I thinX_will continue or may continue to prevent the collection

17

18
19

20
21
22

23

1 24
25

first two sentences,

and

"preached."

in his closing statement

he used the words

I

"concession,"

think they clearly indicate the

that have appeared..

And,

unfortunately,

reliable collection of reliable data.

I think

16

10

15

think the need for that is very clear.

that no matter how our recommendation goes

to

the EMS Committee of the NRC they must somehow provide a means
for collecting reliable data.
this out loud

And I would suggest and I say

that this collection system must be outside of

f_

_^

the people who_are intimately and emotionally involved with the

methods being evaluated.

^**

_______

^>

There is

just no way around that.

And if we don't recognize it, we are going to get intp

the same kicking contest that we got into yesterday and today.

And I repeat to you that and I am not labeling

anybody there were a number of participants

the advice

that somebody once gave mer

a kicking contest with a jackass.

Now, number two, IWould like to question or ask for

further elucidation on the statement just made by Dr. Guildner

in reference to the title volume of a thousand ML.

where he is seated.
Dr.

I don't see

I presume he is still in the room.

Guildner,

could you repeat for me,

please,

your

statement you had relating to limiting title volumes during re

suscitation to 1,000 ML,

10

sures?

so as to avoid esophageal-opening pres

Could you read that to me exactly?

11

DR.

GUILDNER:

12

DR.

BENSON:

I have given it to the chairman.

The statement reads:

"The incidence of

13

gastric distension can be minimized by limiting ventilation

14

volumes

15

esophageal-opening pressures."

to 1,000 cc.

DR.

16

that\here is no point getting into

5T

in the adult,

WEITZNER:

Okay.

thereby avoiding exceeding

I would not argue with the in

17

tent of the statement.

18

for all victims or for all people the amount of airway pressure

19

generated,

20

of people and I am sure you are aware of this in whom you

21

can deliver a thousand ML if you take a somewhat lower flow

| 22
J 23

I am not certain that you can determine

when you deliver a

thousand ML.

rate without generating a pressure

There are any numbe

that we uld the esophagus.

And I wonder if you really wouldn't want to rephrase

I 24

that from the point of view of the maximum airway pressure

1 25

generated by whatever volume applied.

68
1

DR.

saying if you give it if the inspiratory flow rate is slow,

why,

Those are figures that we have found effective in the field of

teaching the public and when we put them on a manikin.

they are simply guideline figures.

there is no question that you can go above those figures.

DR.

Well,

okay,

the reason why I specifi

cally brought that up is that I sat on the gas-powered resusci-

tators panel.

And we made

the recommendation and we purpose .y

10

avoided a specification for title volumes because we don't know

11

the compliance characteristic of the victim. we put our speci

12

fications

13

was

15

in terms of

the maximum pressure generated.

Now all

I am looking for is a reconciliation between

those two ways of stating what I think are the same thing.
DR.

GUILDNER:

I would

like a reconciliation too.

17

is a problem of asking a student,

18

that will result in a better end result.

19

better way of doing it.

20

our students in their practice we can't say to them,

21

exceed 20 centimeters of water in the esophagus.".

22

tell

23

24

I 25

And that

60 centimeters of water.

16

WEITZNER:

And

14

I agree completely with what you are

~)

GUILDNER:

student

to do somethin

And I don't, know a

If we have been successful in limiting

"Don't

You can't

that.

This was

a practical way to approach getting them to

back off and not fill the stomach.

DR.

a lay student,

It

WEITZNER:

But

en*

DR.

DR.

WEITZNER:

DR.

MATORY:

DR.

WEITZNER:

DR.

MATORY:

"Dr. Tucker?

Oh,

I wonder

am

sorry.

Can get together on a statement which yo i

DR.

HUGHES:

Thank you very much.

Thank you.

am sorry;

the gentleman back

there had a gues-

tion.

11

12

Guildner,

might agree upon

10

Dr. Weitzner and Dr.

if the two of you

Dr.

Trevor Hughes,

University of North

Carolina.

13

I.feel privileged to have been present at these pro

14

ceedings.

15

volvement has shown great curiosity.

16

make

And I think that the level of discussion and the in

I would,

however,

like to

a plea.

The plea is that what eventually comes out of this,

17

MATORY:

18

if it is intended for the public and I mean those two millio

19

two

20

SPEAKER:

21

DR.

Hundred million.

HUGHES:

Two hundred million people out there

22

must simple;

it must be direct;

and it must be positive.

We in

23

science and we in medicine learn by a process of training to

24

live with uncertainty.

25

two minutes at the most to save a loved one,

At the time of action, when you have

there is no time

70
1

for theorizing and uncertainty.

We must have a method of action.

Dr.

Heimlich's maneuver at this point in time is that it is cer

tain.

he says ifc_has_worked in 500 cases and is jpossibly^six cases in

the pathological literature which are not written up_yet

of- injuries resulting from this maneuver.

He says we haven't seen the evidence in detail, but

I am almost full-time engaged in teaching people

8
9

~)

The advantage of

medical students,

physicians,

and nurses,

and members

of the

10

public these maneuvers.

I have taught Dr. Heimlich's maneuver

11

for almost two years and find that I can teach it;

12

retention and certainty in the minds of the people I teach it

13

to,

14

feeling they know what to do.

"*

including hospital auxiliary et cetera;

Since the interim standards

15

and they leave.

of the Red Cross have conws

16

out,

I have tried teaching these to physicians,

17

and auxiliary.

18

basis and the scientific gueries behind it,

19

up,

Unfortunately,

and there is

although I see

medical students

the scientific

fliave had to give

You cannot teach uncertainty to a group of people if

20
21

you expect them to turn it on not tomorrow or next week, but

22

sometime

23

ebriated themselves.

in the future,

when they possibly are even a

little, in

24

DR.

MATORY:

Thank you,

sir.

25

DR.

HUGHES:

We must have certainty in what we teach.

71
1

DR.

MATORY:

Dr.

Tucker.

And I think this -- we may have time for just one

other after Dr.

sir.

Tucker.

TUCKER:

Just a brief plea for semantic precision

Dr.

fine.

worried about the public.

we start to talk about the choking patient,

Seeley has

talked about the obstructed patient.

I am worried about the press.

patient who is coughing, who is wheezing,

11

and is not obstructed.

12

Thank you.

13

DR. MATORY:
in the back,

I am
When

who is moving air

; I recognize two more.

and this young man down front.

And it is Dr.

Fin

I am sorry.

I recognize him first because of age.

16

(Laughter.)

is

they think of a

15

17

This

We are all thinking about the obstructed patient.

10

14

DR.

Thank you,

DR. P1NkT~ That comes before beauty, I guess.

18

I would like to make the

19

There was jio__unanimity^^t this meeting,

following comment:
of which I wa

20

a member one of the panel members.

21

get any closer to unanimity by discussion by continuing the

22

discussion here.

23

The important^thing,

And I_dqn_Vt think we can

I believe,

is that the report of

24

the chairman shoulxd reflect fairly the discussiojisthat did go

25

on. ' And I am not certain

I do not -- it is impossible to

72

judge

ciently extensive to give that full impression.

with the chairman that he do that,

tencTit.

from what I have heard here whether that report is suffi

DR.

BENSON:

Mr.

DR.

MATORY:

Yes.

DR.

BENSON:

more.

such a report.

Chairman,

fully agree,

may

I respond to that?

sir.

I could: not agree

I have great difficulty insuring myself that I will writs

I therefore propose that the report be submitte i

to all members of the panel for their review and comment.

11

those of _ygu_who_haye^^ifferent perceptions of what occurred,

12

kindly turn them in;

14

And,

and we will submit them all together.

If you have an alternative proposal,

please let me

know what it might be.

15

DR.

FINK:

16

DR.

MATORY:

17

DR.

SALENGER:

That is

great.

Thank you,

I am Dr.

Dr.

Fink.

Salenger, Medical Director fo

18

Emergency Services

19

seven million individuals and over a thousand paramedics

20

field.

for Los Angeles County, with a county of

in the

I would like to bring tb the attention of the members

21

if necessary that he ex-

10

13

And I plead

22

of

this

committee

that one of

the problems

that we are

faced

23

with and I would like you to consider it in your

24

is we have thousands of potential instructors^ who are waiting

25

for an endorsement by a national organization before they go

final repor

73

out and train an individual.

11 care if there are 14 back slaps and 85 manual
thrjisJbs-*-These individuals,

for medical/legal reasons,

go ahead with the training programs.

in California with
'

We have already had problem:

this.

there

is

a definitive

statement made by the

National Academy of Sciences,

013 the Red Cross and_I_amnot talking about an interim state

ment we have many instructors who cannot inform the public

10

the American Heart Association,

on how to deal with these problems.

11

I hope you will take this into consideration.

12

DR.

MATORY:

Thank you.

13

DR.

BENSON:

Mr.

14

DR.

MATORY:

That

15

DR.

BENSON:

Do you have another comment from the

DR.

MATORY:

No,

DR.

BENSON:

The discussion we had yesterday centered

16

18

19

Chairman
yes?

floor?

17

Unless

will no

that is

the

last comment from the

floor.

20

really around the uncertainty of the data base on which we can

21

make a decision.

22

tions of our recorder,

23

that during the 1800's they Royal Humane Society conducted a

24

25

And I

am tempted
Dr.

to report onepf_jthe_observa

Joseph Redding(?),

who

informed us

2,000 people who allegedly had been resusc

tated by drowning by having large quantities

of tobacco smoke

74
1

administered per rectum.

And I wonder i f we are in

not saying we are.

DR.

I am

I am saying we~3ohft know.

MATORY:

Thank you,

Dr.

Benson.

I have two statements:

I would like to ^I^am^forry that^Dr^JJejjnlich left,

but I would

like

proceedings

and discussions

tolerance and gentlemanly way in which he has responded.

to state my observation that throughout these

I have been very impressed at the
And

10

think

11

lated to

12

that there has been an attempt to try to get both the manual

13

thrust and other aspects of resuscitation adopted,

14

documented evidence,

15

thrust,

16

upon data.

that perhaps
this.

into

there is a significant amount of emotion re

But I do

feel,

as

an observer of the discussion

so as to bring that,

based upon

including the manual

the realm of supported teaching material based

18

and representing the committee

19

this,

20

both in terms of the cooperative effort given by Dr.

21

and by others who had certain aspects of resuscitation which

I 22
| 23

And I hope that and I am sure that the committee

17

the same situation.

the reports

they proposed

the committee will look upon

from the various workshops, with this

to be

considered by

in mind

Heimlich

the workshops.

And representing the committee,

I am sure

I would

I 24

like to remind you there will be a very appropriate evalua

1 25

tion and utilization of the material given.