The Choking Incident: When Abdominal Thrusts Wasn't Enough!

A 3-minute read on managing complex choking cases, when standard techniques fail, and the critical decisions that save lives.

The family celebration at the Italian restaurant was in full swing when I heard the commotion from the table near the window. "He's choking! Someone help, he's choking!" An elderly gentleman was clutching his throat, his face turning red, then purple. His adult daughter was frantically patting his back while other diners looked on in horror. I immediately recognised the universal choking sign – both hands at the throat – and rushed over to help. But as I approached 78-year-old Frank, I could see this wasn't going to be a straightforward case. He was conscious but couldn't speak, couldn't cough, and was rapidly turning blue. After over 5 years of training people through Typhon Training Solutions, I knew that choking can be one of the most terrifying emergencies to witness – and that when the standard Heimlich manoeuvre fails, you have precious seconds to try alternative techniques before the casualty loses consciousness and the situation becomes life-threatening.

The Initial Assessment

Frank was showing all the classic signs of severe choking: he couldn't speak, couldn't cough effectively, and was making high-pitched wheezing sounds as he struggled to breathe. His face was rapidly changing colour from red to purple, indicating that very little air was getting past the obstruction in his throat.

His daughter explained that he'd been eating osso buco – a dish with large pieces of meat and bone marrow – when he'd suddenly started choking. She thought a piece of meat had become lodged in his throat. Frank was conscious and alert, but clearly panicking as he realised he couldn't breathe properly.

The restaurant staff had already called for an ambulance, but I knew that choking casualties can lose consciousness within minutes if the obstruction isn't cleared. Frank was elderly, which meant he might have less respiratory reserve than a younger person, and his panic was increasing his oxygen consumption and making the situation worse.

The First Attempt

I positioned myself behind Frank and attempted the standard Heimlich manoeuvre – abdominal thrusts designed to create an artificial cough that would dislodge the obstruction. I placed my hands just above his navel and gave five sharp, upward thrusts, trying to compress his diaphragm and force air up through his windpipe.

The first attempt didn't work. Frank was still unable to breathe, and his colour was getting worse. I could feel that he was quite frail, and I was concerned about causing injury with more forceful thrusts. Elderly people are at higher risk of rib fractures and internal injuries from abdominal thrusts, but the alternative was watching him suffocate.

I tried another series of abdominal thrusts, this time slightly more forceful. Again, there was no result. Frank was starting to weaken from lack of oxygen, and I could see the fear in his eyes as he realised that the standard first aid wasn't working. His daughter was becoming hysterical, which was adding to the stress of the situation.

The Alternative Approach

When abdominal thrusts fail, the next option is back blows – sharp strikes between the shoulder blades designed to dislodge the obstruction through vibration and sudden pressure changes. I helped Frank lean forward and gave him five firm back blows with the heel of my hand.

The back blows also failed to dislodge the obstruction. Frank was now showing signs of severe oxygen deprivation – his lips were blue, his skin was grey, and he was becoming less responsive. I was running out of standard options, and the ambulance hadn't arrived yet.

I tried alternating between back blows and abdominal thrusts, as recommended in advanced choking protocols. Sometimes an obstruction that won't move with one technique will respond to the other, or to the combination of both. But Frank was still unable to breathe, and I could see that he was starting to lose consciousness.

The Critical Decision

As Frank began to slump forward, I realised that he was about to lose consciousness. Once a choking casualty becomes unconscious, the situation changes dramatically. The muscles relax, which sometimes allows the obstruction to move, but it also means you need to start CPR and consider more advanced airway management techniques.

I helped Frank to the floor and immediately checked his mouth for any visible obstruction. I could see what appeared to be a large piece of meat lodged at the back of his throat, but it was too far back for me to reach safely with my fingers. Attempting to remove it manually could push it further down and make the situation worse.

Frank was now unconscious and not breathing. I had to make a critical decision: start CPR and hope that the chest compressions would dislodge the obstruction, or attempt more advanced techniques that I wasn't sure would work and might cause injury.

The CPR Attempt

I began CPR, starting with chest compressions. Sometimes the pressure from chest compressions can dislodge an obstruction that hasn't responded to other techniques. The compressions also maintain some circulation to the brain, buying time for other interventions.

After 30 compressions, I opened Frank's airway and checked his mouth again. The obstruction was still there, but it seemed to have moved slightly. I attempted to give rescue breaths, but the air wouldn't go in – the obstruction was still completely blocking his airway.

I continued with another cycle of chest compressions, hoping that the repeated pressure would eventually dislodge the meat. Frank's daughter was crying and asking if he was going to die, while other restaurant patrons were gathering around us. I had to focus on Frank while also managing the crowd and keeping his daughter informed about what I was doing.

The Breakthrough Moment

After the third cycle of chest compressions, I checked Frank's mouth again and could see that the obstruction had moved further forward. It was now visible and within reach, but I had to be very careful not to push it back down his throat.

Using my little finger, I carefully hooked around the piece of meat and managed to pull it forward and out of Frank's mouth. It was a large, tough piece of meat that had become lodged sideways in his throat – exactly the type of obstruction that's most difficult to dislodge with standard techniques.

As soon as the obstruction was removed, Frank took a huge, gasping breath. His colour immediately began to improve, and within seconds he was breathing normally again. He was still unconscious from the lack of oxygen, but his airway was clear and he was breathing spontaneously.

The Recovery Phase

Frank regained consciousness about a minute after the obstruction was removed. He was confused and frightened, not remembering what had happened. His throat was sore from the choking and the attempts to clear the obstruction, and he was exhausted from the struggle to breathe.

I helped him sit up slowly and monitored his breathing carefully. Sometimes people who have choked can develop complications like aspiration pneumonia if they've inhaled food particles or vomit during the incident. Frank's breathing seemed clear, but he would need medical assessment to rule out any complications.

The paramedics arrived just as Frank was fully regaining consciousness. They immediately took over his care and began a thorough assessment of his condition. They were particularly interested in the fact that standard choking techniques had failed and that CPR had been needed to dislodge the obstruction.

The Medical Evaluation

At the hospital, Frank underwent a thorough evaluation to ensure that the choking incident hadn't caused any complications. Chest X-rays showed no signs of aspiration, and his throat examination revealed only minor irritation from the obstruction and the removal attempts.

The medical team was interested in why Frank had choked so severely on what should have been manageable food. They discovered that he had some age-related changes in his swallowing mechanism that made him more prone to choking, particularly with tough or fibrous foods.

Frank was kept in hospital overnight for observation, but he made a full recovery with no lasting effects from the incident. However, the experience had shaken him badly, and he was nervous about eating solid foods for several weeks afterwards.

The Family Impact

Frank's daughter was traumatised by watching her father nearly die from choking. She felt guilty that she hadn't been able to help him effectively and worried constantly about it happening again. The family had to make significant adjustments to Frank's diet and eating habits to reduce his risk of future choking incidents.

The incident also highlighted Frank's increasing frailty and the need for more support with daily activities. His family began to consider whether he needed additional care or supervision, particularly around mealtimes.

The psychological impact on Frank was also significant. He developed anxiety around eating and lost weight because he was afraid to eat anything that might cause him to choke again. This required intervention from a speech therapist who specialised in swallowing disorders.

The Restaurant Response

The restaurant staff were shaken by the incident and realised that they weren't adequately prepared for choking emergencies. They immediately arranged for all staff to receive choking first aid training and installed choking rescue devices in the restaurant.

The incident also led them to review their menu and consider whether some dishes posed particular choking risks for elderly customers. They began providing information about choking risks and offering to modify dishes for customers who might be at higher risk.

The restaurant's insurance company also required them to improve their emergency response procedures and ensure that staff were properly trained in first aid. The potential liability from choking incidents in restaurants is significant, particularly when serving elderly customers.

The Training Implications

This case became a crucial example in my choking first aid training programmes. It demonstrates that standard techniques don't always work and that first aiders need to be prepared for complex cases that require multiple approaches.

The case highlights the importance of persistence and adaptability in choking emergencies. When one technique fails, you need to try others, and you need to be prepared to transition to CPR if the casualty loses consciousness.

The psychological aspects of choking emergencies are also important. Casualties are often panicked and may not cooperate with treatment, while family members can become hysterical and interfere with rescue attempts. First aiders need to be prepared for these challenges.

The Age-Related Factors

Frank's case illustrated the particular challenges of choking in elderly people. Age-related changes in swallowing, dental problems, and medications can all increase choking risk. Elderly people are also more likely to have serious complications from choking incidents.

The physical frailty of elderly casualties also affects treatment options. Abdominal thrusts need to be performed more carefully to avoid causing rib fractures or internal injuries. However, the urgency of the situation means that some risk of injury has to be accepted to save the person's life.

The case also highlighted the importance of prevention in elderly people. Modifying food textures, eating slowly, and avoiding high-risk foods can significantly reduce choking risk in this vulnerable population.

The Technical Challenges

This case demonstrated several technical challenges in choking management. The obstruction was large and positioned in a way that made it resistant to standard techniques. The casualty's age and frailty limited the force that could be safely applied.

The transition from conscious choking to unconscious choking required a complete change in approach. This transition is often the most challenging aspect of choking management, as it requires quick decision-making and adaptation to changing circumstances.

The case also showed the importance of direct visualisation and manual removal of obstructions when other techniques fail. This is a high-risk procedure that can make the situation worse if done incorrectly, but it may be the only option in severe cases.

The Legal Considerations

Choking emergencies raise important legal questions about the duty to help and the potential liability for injuries caused during rescue attempts. In Frank's case, the CPR and manual removal of the obstruction could potentially have caused injuries, but these risks were justified by the life-threatening nature of the situation.

Good Samaritan laws provide some protection for people who provide emergency assistance in good faith, but this protection depends on acting within your level of training and not attempting procedures you're not qualified to perform.

The restaurant also faced potential liability for the choking incident, particularly if their food preparation or service had contributed to the problem. This highlights the importance of proper staff training and emergency preparedness in food service establishments.

The Prevention Focus

While this blog focuses on managing choking emergencies, Frank's case also highlights the importance of prevention. Many choking incidents are preventable through proper food preparation, appropriate portion sizes, and awareness of individual risk factors.

For elderly people like Frank, prevention strategies include eating slowly, chewing thoroughly, avoiding high-risk foods, and ensuring that dentures fit properly. Family members and carers also need to be aware of choking risks and know how to respond if an incident occurs.

The case also demonstrates the importance of environmental factors in choking prevention. Eating in a relaxed atmosphere, without distractions, and with appropriate supervision can reduce choking risk, particularly for vulnerable individuals.

The Long-Term Outcomes

Frank made a complete physical recovery from his choking incident, but the psychological impact lasted much longer. He required ongoing support from a speech therapist to overcome his fear of eating and regain confidence with solid foods.

The family made significant changes to Frank's diet and eating arrangements to reduce his risk of future choking. They also ensured that family members were trained in choking first aid so they could respond effectively if another incident occurred.

Frank became an advocate for choking awareness, particularly among elderly people and their families. His experience highlighted the importance of understanding choking risks and being prepared to respond effectively when standard techniques fail.

The Medical Advances

Since Frank's incident, there have been advances in both choking prevention and treatment. New devices are available that can help remove obstructions when standard techniques fail, and there's better understanding of the factors that increase choking risk in elderly people.

However, the basic principles of choking management remain unchanged. Quick recognition, appropriate technique selection, and persistence are still the most important factors in successful choking rescue.

The case also highlights the importance of comprehensive first aid training that goes beyond basic techniques. Real-world choking incidents are often more complex than training scenarios, and first aiders need to be prepared for cases where standard approaches don't work.

The Community Impact

Frank's case raised awareness of choking risks in the local community, particularly among elderly residents and their families. Several community groups arranged choking first aid training sessions, and local restaurants improved their emergency preparedness.

The incident also led to better coordination between restaurants and emergency services in the area. Restaurants now have clearer protocols for calling for help and providing information about choking incidents to emergency dispatchers.

The case became a teaching example for local first aid instructors and emergency responders, helping them understand the challenges of complex choking cases and the importance of being prepared for situations where standard techniques fail.

The Continuing Relevance

Frank's choking incident continues to influence choking first aid training and emergency response protocols. The case demonstrates that even experienced first aiders can face situations where standard techniques don't work and alternative approaches are needed.

The case also highlights the importance of understanding the limitations of first aid techniques and being prepared to adapt when circumstances require it. This flexibility and problem-solving ability are crucial skills for anyone who might need to respond to choking emergencies.

Most importantly, the case shows that persistence and determination can save lives even in the most challenging circumstances. When standard techniques fail, continuing to try alternative approaches and not giving up can mean the difference between life and death.

The Professional Growth

Dealing with Frank's complex choking case was a significant learning experience that influenced my approach to emergency training. It taught me that real-world emergencies are often more complicated than textbook scenarios and that first aiders need to be prepared for situations where standard protocols don't work.

The case also reinforced the importance of staying calm and thinking clearly under pressure. When standard techniques fail, panic is the enemy of effective problem-solving. The ability to remain calm and try alternative approaches is crucial for successful emergency response.

I now always include complex choking scenarios in my training courses, where standard techniques fail and participants have to adapt and try alternative approaches. This helps them understand that first aid is as much about problem-solving and persistence as it is about following protocols.

Want to ensure you're prepared for complex choking emergencies where standard techniques might not work? Contact me on 07939557029 or email mark.phillips@typhontrainingsolutions.co.uk.

Because when someone is choking and the Heimlich manoeuvre fails, knowing what to do next – and having the confidence to keep trying alternative approaches – can be the difference between a successful rescue and watching someone suffocate despite your best efforts.

Mark Phillips provides comprehensive choking emergency training through Typhon Training Solutions, helping people prepare for the complex choking cases where standard techniques fail and quick thinking and persistence become the keys to saving a life.