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Clinical Story of the Month

(Copyright Stemmler, 1998)

"Watching HOW you Eat: a Matter of Life and Death"


Every year, 3,000 deaths are reported in the U.S. due to aspiration asphyxia.

Many of you may have heard the story of some famous actress who choked to death while finishing up a box of bonbons in the privacy of her luxury hotel suite. And, tragically, nobody even noticed it until the next afternoon, when she was finally found by an impatient maid, ready to go off her shift after completing her last room assignment.

Or you may even remotely known somebody who choked at a large banquet, surrounded by horrified guests paralyzed in fear and confused about how to proceed. Could it be a heart attack, a stroke, a convulsion or even an acute appendicitis? In the meantime, the patient was clutching his chest and his throat, unable to utter a word or take a breath. Initially he turned red, then blue, and eventually lost consciousness and died 4 to 5 minutes later. By the time the ambulance arrived, nothing else could be done for him. A few days later, his cause of death was reported by the coroner as: "asphyxiation resulting from food lodged in the larynx".

So what could the horrified guests have done instead?

And so here comes the story. You will be surprised when you realize that most of you know the two people who recently choked in our practice, and who could have died within a few minutes of choking, had they not received prompt intervention.

The first person who choked during an enjoyable and relaxed dinner at our house in Tucson last Spring was our very own Peter. I had cooked a delicious roast that evening, and Peter was real hungry. As he was reaching for a nice, big, juicy piece, he was complimenting me with ah’s and uh’s, when he suddenly stopped in mid-sentence. He dropped his fork and knife, and clutched his throat without making a sound. One look at him was enough to know it was the meat and not his heart. I rushed towards him and performed a Heimlich maneuver in the standing position. On the third thrust, the piece of meat popped out like a cork, and Peter smiled with relief. The whole incident lasted only 30 to 40 seconds, and Peter never had time to become real distressed nor oxygen-deprived . Yet, had another minute or two elapsed, the situation would have been quite different. As it was, we continued to eat, although somewhat more carefully, and we enjoyed the rest of the evening without any further events.

Six months later, on an early Monday afternoon in Houston, we had just finished seeing our patients for the morning, when the first patient scheduled for the afternoon rang the bell at the reception desk. Sandy, our busy, hard-working nurse popped in a piece of meat and walked towards the front office, with just enough time to chew and swallow before greeting the patient. Then the phone rang. Of course she automatically reached for it, even though she had a mouthful. So, instead of chewing, she inhaled deeply to enable her to answer with her customary long greeting: "Dr Stemmler’s office…this is Sandy…how may I help you?" But she never said a word. Suddenly she could not breathe and she could not speak; she had choked on her food. Her first reaction was to reach for some water, just to realize that she could not swallow either. She tried to cough, yet she was not able to. She tried to breathe, yet she was not able to. She tried to scream, yet she had lost her voice. Then she panicked. She ran towards me, her eyes wide open, gesturing with her arms, pointing to her chest and throat. Fortunately I just happened to be walking into the nurse’s station, rather than being in a room performing a Pap smear or other procedure. That rare circumstance probably bought us 2-3 minutes of vital time. I stood behind her and performed three Heimlich maneuvers with no results. After two more I let Drina, our then part-time R.N. try a few times, also without results. Our other four staff people were trying to call 911. Ironically they were all put on hold "because the lines were busy", and it was probably us jamming the lines!

By then Sandy was desperately gasping for air, trying to say a thousand things and not being able to utter a single word nor inhale a single breath. Then she began to turn blue and I realized for a split of a second that she was going to die. And, in the same split of a second, I determined that she was NOT going to die. Not Sandy, not today, not here in our office, just in front of us, not this young, not because of a piece of food, no, not, absolutely not, period. My medical training was quickly overidden by common sense and a deep survival instinct that emerges in all of us when the alternative is death. I had to open an airway for her, regardless of the method used. I reached inside her mouth with my entire hand and hooked a little piece of meat out of the back of her throat. Then I heard a wheeze. The sweetest, little sound I had heard in a long time. "You’re breathing, Sandy!" , I said (I screamed, I believe), "You’re breathing, you won’t die!" As she started to regain some color, from a fading blue to a shy pink, she began to fuss at me with gestures, wheezes and moans, trying to let me know that there was more work to do before we could really celebrate. "I know", I said, I’ll get it out". I reached back into her mouth, my knuckles past her teeth (only later did I notice my war injuries), and I hooked up the biggest treasure (a respectable-sized piece of meat) I had hoped to hunt in my lifetime! "Forget 911!" , I called over to all those on hold. Sandy turned pink right away, and for at least two to three minutes, Drina and I held her real close to us, like a newborn, savoring her return, and soothing her wounds of a near-death experience. Of course, Sandy had to listen to lectures from her husband, her family and all of us for the rest of the week. But she will also be pampered and given special treatment for a long time. She deserves it and needs it.

From Sandy’s perspective, those 2-3 minutes seemed like an eternity, and she reported seeing everything around her as if in slow motion. She never felt the impact of the Heimlich thrusts, yet later complained about sore abdominal muscles. Her reflexes and her ability to feel touch and pain were shutting down without the oxygen necessary for normal nervous function. Even her gag reflex was completely absent when I reached far back into her throat to dislodge the obstacle. I felt absolutely no resistance and, in a way, it facilitated my job at the time.

None of us have been the same since these two incidents. They have taught us a lot and, hopefully, they will be of benefit to you, your family, friends, and acquaintances.

Many of the patients who were in the office on that Monday asked us to write this up. And Sandy and Peter were gracious and generous enough to share their very frightening (and somewhat embarassing) experience with you, so that your life or that of a loved one can be saved, should this ever happen to somebody in your presence.

I would like to thank both of them and celebrate their return to life.

But I will not stop here. Not before I teach you what you can do if you happen to be in the presence of a choking victim:

#1- Do not get paralyzed by fear, and do not run around like a chicken with its head off.

#2- Stay calm but act promptly.

#3- You only have 3-4 minutes to act effectively, and 4-6 minutes before organ damage sets in (brain, heart, kidney can’t breathe,), when you are faced with a complete obstruction of the airway: can’t breathe, can’t speak, can’t swallow.

#4- Start with a Heimlich maneuver. Repeat three to five times; then proceed with the next step. Doing "more of what doesn’t work " could kill the patient.

#5- Put your hand into the patient’s mouth, and reach as far back as possible with your index finger curved slightly like a hook at the last two joints.Be careful to hook the material and sweep it out, rather than pushing it in further, sealing the obstruction even tighter.

#6- As soon as you hear the patient’s voice and breathing sounds, as long as the patient is awake and alert (and not too frightened), you may let them cough it up by themselves, if at all possible.

#7- If after two or three finger sweeps you are unable to relieve the obstruction, you may need somebody else to pry the mouth open (even if you have to break the jaw – something that can be fixed later - death cannot), and then use a long instrument (medical forceps, kitchen tongues or pliers), to grasp the obstructing object and pull it out.

#8- In a real desperate case, when everything else has failed and death is imminent, the only option may be a cricothyrodotomy, which consists of making a cut into the cricothyroid membrane, a thin lining between the thyroid cartilage (which is embraced by the thyroid gland, and is also known as "Adam’s Apple", and is usually more prominent in men) and the cricoid cartilage, which is situated right below it. In a dire emergency, a pocket- knife and a pen is all that is needed until professional help arrives. Yet, this procedure is not without complications, so it is better to have previous training in it. If you wish to obtain more information on this procedure, let me know at your next office visit.

You can learn your Heimlich maneuver at various places: the Red Cross, on 59 between Kirby and Buffalo Speedway, and at most area hospitals. You may also find some nice laminated instruction posters at Major’s Scientific Bookstore on Fannin, between Old Spanish Trail and Holcombe, or you can pick up handouts describing the procedure in our waiting room.

The ultimate lesson is that PREVENTION is better than the cure. Remember to only eat at mealtimes or snack-times.

Do not:

-Eat and talk

-Eat and watch TV

-Eat and read (You still move your tongue and larynx as if you were talking)

-Eat and get upset

-Eat in bed

-Eat on the run

-Eat and drive

-Eat and answer the phone (Sandy added this one!)

Even though your larynx (the beginning of your pipeline) is in front of your esophagus (your swallowing tube), the larynx has a cute little "sunroof" called epiglottis, which closes when you swallow, so that the food can slide over it and into the esophagus, and which opens when you speak, laugh, or sing. If you happen to swallow and talk at the same time, your "sunroof" might be open while your food is still on its way down…and then you choke!

And remember that people do not just choke on meat (Attention you vegetarians!), but it is just as easy to choke on veggies: avocado, asparagus, bananas, apples (remember Snow White?), and bread!

Be especially careful during the coming holidays, when families get together and eat, talk and laugh, often all at the same time, trying to catch up for the rest of the year.

Have a safe and happy holiday, and be sure to chew that turkey, the trimmings and all your veggies!


Christina Stemmler, MD

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