The conflict between combat sports and ethical medicine: can they co-exist?

The conflict between combat sports and ethical medicine: can they co- exist?

N K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY, United States of America
Corresponding author: N K Sethi (sethinitinmd@hotmail.com
Disclosure: The author serves as the Chief Medical Officer of the New York State Athletic Commission (NYSAC). The views expressed above are those of the author and do not reflect necessarily the views of the New York State Athletic Commission.

Address correspondence and reprint requests to:
Nitin K. Sethi, MD
Associate Professor of Neurology
Comprehensive Epilepsy Center
New York-Presbyterian Hospital
Weill Cornell Medical Center
525 East, 68th Street
New York, NY 10065
Email: sethinitinmd@hotmail.com
Tel: + 212-746-2346
Fax: + 212-746-8845
Even after so many years, there are times when my love and passion for combat sports collides head on with my love and passion for medicine and protecting athletes health.

One would assume that these 2 passions would not cause any conflict in me and for a while it never did. On many weekends, I would be at Mendez Boxing hitting the bag while wearing my favorite T-shirt proudly emblazoned “Neurologist-because awesome is not a job description”. My friends at Mendez know me and call me simply “doc” and some of my most memorable moments have been spent in their company discussing combat sports.

I once gave a lecture to a body of my peers at my hospital. The topic I chose was “Neurological injuries in boxing”. I spoke passionately about the topic. To my dismay, many of my colleagues disagreed with my involvement in combat sports and got up and left midway. I felt hurt but my passion and love for both combat sports and Neurology remained unchanged. But recent events have forced me to come to terms with my involvement as a ringside physician in combat sports.

One principle has always helped me when I find myself struggling and that is that I am there ringside or cage side for only one thing. To stop a fight once I feel the threshold has been reached beyond which I cannot guarantee a fighter’s health and safety.

The fighters are professionals skilled and trained to do their job. They always command my greatest respect. I too am a professional skilled and trained to do my job. My threshold of stopping a fight may differ from a fighter or a fan’s threshold of stopping a fight. It may also differ from a referee’s threshold of stopping a fight. As a physician one cannot defend combat sports by saying that boxing or MMA is good for the brain or the body. No amount of boxing or MMA is good for the brain-not one round, not even one punch to the head or to the body. Ringside or cage side I need to remain objective, completely free of any bias and make a call to stop a fight based solely on the medical facts in front of me not the fighter’s fight record and certainly not based on how big the fight is and how much money is at stake. The minute I do that, I fail to remain an objective doctor and I rather be a spectator occupying a seat at the venue rather than wasting a seat ringside or cage side. My judgement is going to be biased and I am now primed to fail in my only duty which is to protect the athlete’s health.

Do I have all the answers? No. But sometimes under tremendous pressure I must make a call. It does not matter whether the setting is the ER, the ICU or the bright lights of a combat sports arena. Why would I treat a patient that I am seeing in the ER after an assault on the street differently from an athlete who has sustained similar injuries inside a ring or a cage? If I am concerned about an assault victim, I am not going to tell him all is well and just discharge home from the ER. No, I shall admit him and do the necessary medical evaluation and management. Why should my approach be different cage side or ringside just because it is a big fight? If it is, I have no right to be present there for I am failing my patient (the athlete) who has trusted me with his/her health on entering the cage or the ring.

The ringside/ cage side setting is far more challenging to practice medicine than the controlled environment of the ER or the hospital. I must make a call and I must make it fast. I do not have the luxury of doing labs or a CT scan. It is all clinical with only the athlete in front of me. And yes, contrary to some people’s view it does take 15 to 18 years of intense medical training to make this call-which athlete has only suffered a concussion and can be discharged home versus one who may be about to develop a far more serious traumatic brain injury. You only have to encounter an unconscious person on the street to realize how tough it is and how helpless you feel without a doctor on hand. And I need to make the right call for there may never be a second chance for me to re approach my patient and change my decision.

It is unfortunate and dangerous when an experienced referee, inspector, judge or ringside physician is afraid to make a call because he/she is worried how the decision shall be viewed by the public and other parties. When they are worried whether their decision is going to cost them the opportunity of working the next “big” fight. Would you (if you were a patient) trust this doctor with your most precious possession of good health?

I am not saying that medical decision making in combat sports should not be critically appraised. Every medical stoppage should be looked at, studied and learnt from. Was it right or was it wrong? But there is a way to do this and it is not online. Telling a doctor that he is a “fucking scum”, screaming for his blood so that he fears for his own health and safety as he heads out of the arena is certainly not the way. Thrashing his reputation online is also not the way. Most ringside physicians practice ringside medicine a mere 1% of their total time practicing medicine. We work in hospitals and we have regular jobs. We do not do ringside medicine for the money. We are paid anywhere between $200 to $400 for the night, a night where we tirelessly work upto 12 hours under exceptionally difficult circumstances. That is below minimum wage. We do what we do because we care.

It is understandable why even my own peers in Neurology and Medicine do not support the work of ringside physicians and call for a ban on all combat sports. Combat sports and ethical medicine cannot co-exist without conflict. The gap is too large to bridge.

Today, I again struggle to bridge my love for medicine and combat sports.

Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight

Standardized Concussion/ Traumatic Brain Injury Screening Protocol for Boxers and MMA combatants during and after a fight

Nitin K Sethi, MD, MBBS, FAAN
Chief Medical Officer, New York State Athletic Commission
Associate Professor of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY 10065 (U.S.A.)

Disclaimer: the views expressed in this article are mine and do not necessarily reflect the views of the New York State Athletic Commission (NYSAC).

 

In the ring and cage during a fight:

1. If concern for concussion or traumatic brain injury arises during the course of the bout, the ringside physician shall assess the combatant preferably between the rounds. The evaluation will be carried out by the ringside physician during the 1-minute break between rounds or after the 1-minute break but before commencement of the next round by requesting the referee to call a time out. The ringside physician shall assess the combatant with the use of Maddocks questions. Maddocks questions include but are not restricted to:

a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?

2. The ringside physician shall conduct a focused neurological evaluation of the combatant in the ring/cage. This evaluation shall include:

–asking the combatant if he/she has any subjective complaints such as headache, dizziness, visual disturbances, nausea, feeling off-balance.
–giving the combatant a two-step command (touch your right ear with your left glove).
–assessment of pupil size symmetry and reactivity (integrity of cranial nerves II and III)
–assessment of extraocular movements (integrity of midbrain and pons by assessment of cranial nerves III, IV and VI)
–assessment of cerebellar function and infratentorial compartment integrity by checking gait and stance (stand still with feet together and/or tandem gait).

The ringside physician should be aware of the NO-GO criteria. If any one of the NO-GO criteria is present, consult with Chief Medical Officer (CMO)/Assistant Chief Medical Officer (ACMO) and consider advising the referee to stop the fight on medical grounds.

The NO GO criteria are the following:

1. If the combatant exhibits any period of LOC or unresponsiveness after a KO.

2. if the combatant exhibits confusion (any disorientation or inability to respond appropriately to questions) at time of assessment by ringside physician.

3. If the combatant exhibits amnesia (retrograde / anterograde) when assessed by the ringside physician. The ringside physician shall assess for retrograde and anterograde amnesia in the ring/cage using Maddocks questions including but not limited to:

a) What venue are we at today?
b) Who are you fighting today?
c). What round is it now?
d). Who did you fight last?

4. If the combatant voices to the ringside physician or his corner any new and/or persistent subjective symptoms such as headache, nausea, dizziness.

5. If the combatant vomits during the course of the fight (this criterion should not be used in isolation to stop a fight on medical grounds).

6. If the combatant has an abnormal neurological examination (ataxia, impaired balance, pupil size asymmetry and/or reactivity) when assessed by the ringside physician.

7. If the combatant has a concussive seizure also at times referred to as an impact seizure (seizure occurring at the time the fighter’s head makes impact with the ring/cage canvas).

 

In the post-fight examination area/locker room after the fight is over

The ringside physician shall assess for the presence or absence of concussion/ traumatic brain injury with the aid of a multimodal concussion screening and assessment battery including but not limited to:

a) Glasgow Coma Scale Score (best motor response, best verbal response and eye-opening). CGS score less than 13 is mandatory transfer to the emergency department (ED) of the designated Level I Trauma Center via on-site ambulance for urgent CT scan head to rule out acute traumatic brain injury.
b) Detailed neurological examination including higher mental function testing, cranial nerve II to XII testing, pronator drift testing, assessment of motor function, finger to nose testing, tandem gait assessment and Rhomberg’s test.
c) Standardized Assessment of Concussion (SAC) test-check orientation, immediate memory, concentration, delayed recall (see attached SAC form).
d) Balance Error Scoring System (BESS) test-double leg stance, single leg stance and tandem leg stance (see attached BESS testing procedure).

Management of a concussed combatant is on a case by case basis with majority of combatants discharged from the venue with a medical suspension. Duration of the suspension may vary from 30 to 90 days with mandatory 90-day suspension and follow up with a neurologist if the concussion occurred by a KO. All combatants discharged home from the venue are instructed to remain in close observation of a family member/coaching staff for the next 24 hours with instructions to report to the nearest emergency department (ED) if any neurological symptom (headache, dizziness, blurred vision, vomiting, impaired balance) or sensorium (lethargy, unresponsiveness) is reported. All discharged combatants are educated about post-concussion symptoms with instructions to seek medical care if these are reported. A combatant may be referred to the ED of the nearest Level I trauma center for an urgent CT scan of the head and further evaluation if deemed appropriate by the ringside physician. Transport in these cases shall take place via on site ambulance.

References

 

1. Neidecker J, Sethi NK, Taylor R, Monsell R, Muzzi D, Spizler B, Lovelace L, Ayoub E, Weinstein R, Estwanik J, Reyes P, Cantu RC, Jordan B, Goodman M, Stiller JW, Gelber J, Boltuch R, Coletta D, Gagliardi A, Gelfman S, Golden P, Rizzo N, Wallace P, Fields A, Inalsingh C. Concussion management in combat sports: consensus statement from the Association of Ringside Physicians.Br J Sports Med. 2019;53(6):328-333. doi: 10.1136/bjsports-2017-098799.

2. Erlanger DM. Exposure to sub-concussive head injury in boxing and other sports. Brain Inj. 2015;29(2):171-4. doi: 10.3109/02699052.2014.965211.

3. Jayarao M, Chin LS, Cantu RC. Boxing-related head injuries. Phys Sportsmed. 2010;38(3):18-26. doi: 10.3810/psm.2010.10.1804.

4. Galetta KM, Barrett J, Allen M, Madda F, Delicata D, Tennant AT, Branas CC, Maguire MG, Messner LV, Devick S, Galetta SL, Balcer LJ. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters. Neurology. 2011 Apr 26;76(17):1456-62. doi: 10.1212/WNL.0b013e31821184c9.

5. Potter MR, Snyder AJ, Smith GA. Boxing injuries presenting to U.S. emergency departments, 1990-2008.Am J Prev Med. 2011 Apr;40(4):462-7. doi: 10.1016/j.amepre.2010.12.018.

6. Sawauchi S, Murakami S, Tani S, Ogawa T, Suzuki T, Abe T. Acute subdural hematoma caused by professional boxing. No Shinkei Geka. 1996 Oct;24(10):905-11.

Good versus bad medical stoppages in boxing-stopping a fight in time

Good versus bad medical stoppages in boxing-stopping a fight in time

 

Nitin K Sethi, MD

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY (U.S.A.)

 

 

 

 

In boxing it is commonly said and not without reason “the fight must go on….”.  Everyone ringside wants the fight to go on-the two boxers and their corners (sometimes not always!), the promoter (always!), the media (always!), the spectators (always!), the Commission and its appointed officials (only if both the boxers meet the Commission requirements for a fair and honestly administered contest), the referee (only if the boxers are fighting a fair fight and able to defend themselves), the judges (usually do not interfere with the conduct of the fight!) and the ringside physicians (only if the boxers are medically fit before, during and immediately after the contest!). So everyone ringside want the fight to go on but do some (media, spectators and promoters) want it more than others? As per the Uniform Boxing Rules (approved August 25, 2001, Amended August 2, 2002, Amended July 3, 2008), the referee is the sole arbiter of a bout and is the only individual authorized to stop a contest. In some states in the United States and in countries around the world both the referee and ringside physician are the sole arbiters of a fight and are the only individuals authorized to enter the fighting area at any time during competition and authorized to stop a fight. The referee and the ringside physician threshold to stop a fight (enough is enough!!!) may vary based on knowledge of boxing rules and regulations, knowledge of the boxers fitness level, pre-existing medical conditions, pre-bout fitness, intra-bout fitness and finally knowledge of medicine and bout ending injuries (head injuries, orthopedic injuries, eye injuries, blunt abdominal trauma). That is the reason why it is the referee (someone who has knowledge of boxing rules and regulations) and the ringside physician (someone who has knowledge of medicine) who are deemed to be the sole arbiters of a bout and entrusted with the health and safety of the boxers. The other MORE important question is when should the fight be stopped on medical grounds? Stopping the bout prematurely is unfair to the boxers, their corners, the promoter and the public. Stopping a bout too late risks serious injury even death of the boxer.

Boxer safety should precede all other considerations. The goal should be to stop the bout before a life threating injury or career ending injury occurs. Key word is before NOT after. Since at times this is not possible so more realistic goal should be timely identification of a serious injury in the ring and timely stoppage of fight. For that to occur the referee and the ringside physician should work as a team complimenting each other’s knowledge. Causes of sudden death in the ring or in the immediate aftermath of a bout are usually neurological.

To help timely identify and prevent TBI in boxing the following good practice guidelines are proposed based on personal and collective evidence of experienced ringside physicians and clinical acumen:

 

  1. It is a good point to remember that boxers rarely if ever voluntary quit or request the fight to be stopped. They fight for pride, at times at the expense of their health. Corners may also not want the fight to be stopped with the hope that their boxer may turn things around. In a closely contested fight the crowd is excited and wants the fight to go on. At these times, the ringside physician should make the call to stop or let a fighter continue, based solely on the medical condition of the boxer.

 

  1. During the one minute rest period in-between rounds, the ringside physician should step up to the ring canvas for a quick but thorough medical evaluation of the fighter.

 

  1. This is the ideal time for the ringside physician to assess the neurological status of a fighter. In the case of a fighter who suffered a knock down in the preceding round or sustained multiple head shots, the ringside physician should conduct a quick visual evaluation of the fighter (Is the fighter responding appropriately to the commands and directions of his corner? Is he making eye contact with his corner staff? Was the fighter steady on his feet as he walked back to his corner at the end of the round? Does the fighter voice any complaints to his corner staff such as headache or pressure in head, dizziness, and blurred vision?). The ringside physician should attempt to do the above without obstructing or imposing on the corner’s time with its fighter.

 

  1. If the ringside physician determines that he/she needs more time to evaluate the neurological status of a fighter, he/she should communicate this to the referee. The referee after starting the bout shall call a time out and walk the fighter to the ringside physician to be examined. The referee directs the other fighter to remain in the neutral corner. The ringside physician’s goal at this time is to conduct a quick but thorough neurological assessment of the fighter. He/she should begin this by asking the fighter few leading questions such as-how do you feel? Does your head hurt? Do you know where you are? If the fighter appears confused and disoriented, the ringside physician may ask more question like which round is it? Who is your opponent? Where are you fighting (name of the venue)? The ringside physician should then look for pupil symmetry and response and assess extra ocular movements (have the fighter track finger from side to side). The ringside physician should give the fighter a complex command such as touch your left ear with right glove and should assess the fighter’s gait and balance at the same time (is the fighter steady on his/her feet or is he leaning on the ropes for support). The ringside physician should then communicate to the referee whether the fighter can continue or the fight should be stopped. The whole process should not take more than 10 seconds.

 

  1. The ringside physician should be aware that too much time spent evaluating the fighter during time out, inadvertently gives the fighter more time to recover. The opponent’s corner rightfully resents this and it is akin to getting “saved by the bell”. The public, TV audience, press and TV announcers question the fairness of the Commission’s administration of the contest and the credibility and impartiality of the bout officials-e.g., referees, judges and ringside physicians.

 

  1. If serious health concern is raised for a fighter and the ringside physician is unable to document a good exam to determine whether it is safe for the fighter to continue, consideration should be given to stopping the fight. In these circumstances the ringside physician should tell the referee that the fight be stopped on medical grounds.

 

  1. For ringside physicians with limited ringside experience, it is encouraged that they consult with other ringside physicians at the venue and the chief medical officer before deciding to stop a fight on medical grounds.

 

 

 

 

 

 

 

 

As injuries mount, the boxing community is looking within and the sport is under scrutiny from the medical community and media. Boxing is the most controversial sport for physicians and neurologists in particular because of the potential risk and degree of neurologic injury, questions and concerns about long-term sequelae (chronic traumatic encephalopathy), and the occurrence of deaths in the ring  . Various medical associations including the American Medical Association and the American Academy of Pediatrics have stated opposition to both amateur and professional boxing . Many have called to ban boxing altogether . Dr. Hauser in a recent editorial titled “Beaten into action: a perspective on blood sports” says that “the medical, and especially the neurology, community has an obligation to do more. We need to spread the word that brain bashing is not a socially acceptable spectator sport, and partner with our national organizations to expand and improve the effectiveness of public awareness and other educational initiatives.” He further goes on to state “we should forcefully counter articles in the medical literature taking the position that closer medical supervision could obviate the need for a ban, or even worse that consenting adults have the ethical right to maim each other if they choose to do so .” While the neurological risks of boxing cannot be completely eliminated, boxing can be made safer .

 

 

 

Conclusion

 

 

It is recommended that the above proposed best practice guidelines be debated vigorously by the ringside physician and large scientific community and evidence based guidelines on medical stoppages be developed by the medical community in conjunction with professional boxing governing bodies. Boxing can be made safer but it shall be foolhardy to forget that frequently there is a very fine line between a good medical stoppage (medical stoppage done at the right time during the bout and for the right indication) versus a bad medical stoppage (medical stoppage done either too late, too prematurely or for the wrong indication). It is far better to stop a fight early rather than late. A ringside physician should never forget that in boxing one punch can change everything. One punch can kill!


 

Making Boxing Safer

Boxing as a sport is close to my heart. Boxing is also a sport with a high risk for traumatic brain injuries. Ringside physicians are entrusted with the health and safety of boxers and combatants of other contact sports such as MMA. The health and safety of boxers is something I am passionate about.

boxer-safety-final-edited

The Powerpoint presentation reflects some of my thoughts on how boxing can be made safer primarily targeted at referees. It talks about the importance of constant communication between ringside physicians and referees. The views and opinions expressed are entirely my own. They do not reflect the views of the New York State Athletic Commission or any other boxing governing body. I disclose that I work for the New York State Athletic Commission as a ringside physician.

 

Nitin K Sethi, MD

Chronic traumatic encephalopathy-making the games we play safer

New data indicates the ever present danger of chronic traumatic encephalopathy (CTE) in contact sports such as boxing, mixed martial arts (MMA), football, ice-hockey and even soccer.  Contrary to popular belief it is now felt that it is just not concussive injuries but even sub-concussive injuries which can predispose an athlete to CTE. This may be of importance to a soccer player who repeatedly heads the ball during play. There are other questions for which we still do not have a good answer.

1. How many concussions are needed and how severe they need to be for CTE to develop? Is there a limit beyond which the brain loses its capacity to compensate for chronic trauma and signs and symptoms of CTE appear? If so what is this limit? Can it be defined? If a player stops playing before this limit is reached would CTE be aborted?

2. Once CTE develops can it be reversed?

3. Is there a way to protect the brain from developing CTE apart from changing the way the games are played. Changing the rules of the game (such as avoiding head butts during football, heading the ball in soccer, direct blows to the head in MMA, wearing safety gear/helmets) shall certainly help but are there other neuroprotective strategies such as medicines (antioxidants, anti-inflammatory drugs) which can be given to prevent the onset and progression of CTE?

As you can see there are many questions for which we still lack good answers. Making the games we play safer certainly sounds a logical principle and hence the thrust to identify concussions in a timely fashion on the playing field and rest the player till complete recovery is documented. Neurologists, neurosurgeons and other physicians skilled in neurosciences by virtue of their training are better equipped to identify concussions and thus there is a growing call to have them by the side of the playing field in every professional and now even college level game. Biomakers and imaging markers to identify CTE in the living brain are also been explored.

Till more is known about CTE and more importantly on how to prevent and reverse it, making the games we love and play safer should be the goal.

 

Nitin K Sethi, MD