They are in no particular order or
significance, just thoughts.
As in all professional organizations,
continuing education and established training and experience
creates consistency and quality.
1. Consider establishing a Medical Board to
review all deaths and serious injuries. (Dr. Alan Fields would be
the perfect Chair to organize this Board). The Board should have
a representative from the field of Neurology or Neurosurgery,
Ophthalmology, Ear, Nose and Throat as the basis with
possibilities of a Physical Medicine and Rehabilitation and
Orthopedist as alternative members. These should be Board
Certified in their specialty, attended at least one annual
conference and had at least two years of physician boxing
experience. They can review and amend the practices of ringside
physicians as well as review post fight injuries. They can also
help clarify clearances to fight in cases of questionable medical
conditions for fighters.
This group can coordinate a summary for all
deaths to give recommendations on any revisions to pre fight
physicals of post fight examinations. All reports would remain
with the commission.
As trainers and managers fail to reveal any
history of injury, subsequent findings by physicians in the pre or
post fight examinations that find objective evidence of obvious
medical problems of concern should be reviewed by this Board and
if appropriate make recommendations of suspensions of the
fighter's representatives.
2. Medical Guidelines of Care in Pre and
Post Fight Situations. Physicians need standards of care to
ensure that expectations of care and treatment are outlined before
the event.
(a) Post Fight Suturing of cuts. Some cuts
can be managed by Steri-strips of Band-Aids, but some require
sutures. Objective guidelines should define the difference. As
cost is involved with the treatment of these lacerations, some
physicians who suture in their practice offer the suture the
lacerations in the fighter's locker room. Other physicians who do
not regularly suture, refer to the local medical facility.
Concern to non-suturing physicians is the lack of a sterile
environment in the training room, but more importantly, lack of
consent to treat, lack of follow-up care and the cleanliness of
the wound before closure. The burden of litigation should an
infection like MRSA (the flesh eating bacteria) would be high as
no consents are signed and lack of documentation of services
provided.
(b) Guidelines to post concussion
headaches. As physicians we should have a sheet that summarized
types of headaches and when a fighter should seek medical help as
emergency room do with pre-printed fact sheets on every medical
condition. This at least gives some direction to the fighter and
his trainer of warning signs of a intra-cranial bleed. This
information sheet can be easily copied as all Emergency Centers
have pre-printed information. We would need the Medical Board
approve which sheets are appropriate to use. These sheets should
be copied and available from the commissioner at the event for the
physician to request.
(c) For new physicians we need a small
handbook to common fight injuries and how to care for them.
Examples include, septal maxillary fractures, wrist bone
fractures, biceps ruptures, knee and other joint injuries,
lacerations that effect the boxer versus non-interfering
lacerations and bleeds, eye injuries and signs of neurological
changes including simple concussions.
(d) Information for physicians on over the
counter medications that are allowed versus not allowed. Inform
them of the post test urine screen and what types of substances
they are screening.
3. New physicians are at a disadvantage
(unless Dr. Alan Fields is assisting) in knowing what is expected
of them as frequently each physician approaches the pre and post
fight physicals with a wide spectrum of variation.
(a) New physicians should be required to
assist in their first fight with a "senior" ringside physician,
such as to get proper "orientation" to the situation. The
"senior" physician should be paid more on that first event as he
serves as a mentor and is teaching the new ringside physician.
(b) New ringside physicians should attend
one conference from the Boxing Association for Continuing
Education within the first year or two of their participation to
recertify their expertise. This certificate of participation
should be faxed or mailed to the Boxing Commission and tracked.
(c) As all other officials of the Commission
are evaluated for their basic competence, a periodic review of the
ringside physician should be created and the more competent and
experienced physicians should hold precedent in determining
assignability to events. Main events should only be attended to
by the most experienced ringside physicians. The designation of
experienced ringside physicians should be "senior" and a list
should be created to rank the physicians as well as noting the
regions that they can best serve.
(d) Physicians need to understand the
differences in boxing versus mixed martial arts. Although an
experienced ringside boxing physician, attending a mixed martial
arts venue is treated as a novice physician as there are new rules
and screens that need to be performed by the physician.
4. Boxers-Fighters do not "share" any
history of surgery, trauma, recent infections, eye damage to the
physicians. One reason is that physicals are done in an open
setting with no privacy. Frequently the opponent is sitting
alongside his opponent and trying to find weaknesses in the
boxer-fighter. Exams need to be held one on one with privacy as
is expected in any medical setting.
5. Lack of Boxer-Fighter Past Medical
History. As in all other sports a baseline physical is made by
their own primary physician to starting a sport, especially in
high school and college, a boxer may be required to have an annual
physical by his primary physician in the past two years of his/her
event. This places a large burden or medical liability on the
primary physician should any pre-existing injuries of surgeries be
hazardous to further contact sports. Additional information
needed in an emergency situation (usually an unconscious boxer)
are Medication Allergies, Blood Type, Vaccinations up to date,
Recent Medical history as well as contact telephone numbers of
spouse, parent, significant other who can provide any information
as well as kept informed of the medical status.
6. Change in neurological status is critical
to the diagnosis of a medically serious and life threatening brain
injury. The post fight Glasgow Coma Scale is a 15 point scale.
Almost always a 15 is given. Any number less than 15 needs to be
sent to the Emergency Room for diagnostic testing to assess for
possible bleed in the brain. As a secondary safety and medical
review, all non 15 scale numbers should be referred to the Medical
Board (to be created) for review and summary comments to be given
to the commission. A summary of any non 15 score should contain a
concise medical documentation post fight by the examining ringside
physician.
7. Continuing Education. This is done by
the internet of conferences. Consider creating a monthly email
newsletter from the Boxing Commission that has some interesting
topics that update the ringside physicians and hopefully improve
their boxing-mixed martial arts knowledge. If possible, these
medical topics could be created to give Continuing Medical
Education credits for physicians as well, but this takes effort
and time, not the least money.
8. Paramedics who assume care of a boxer
they have no idea of history are at a significant disadvantage. I
propose that copies of all pre fight physicals of the boxers be
copied, placed in a sealed envelope for confidentiality and given
to the paramedics who are at the event. In the case of an injured
boxer, they can open the envelope, find the participant and start
relaying medical information to the emergency room physician the
history of the patient. As more than one boxer may be injured, a
second copy should be made and be available to the next team of
paramedics. Cell phone numbers of the physicians who performed
the pre-fight physicals should be given to the paramedics in case
the emergency room physician needs to contact the last doctor to
examine the fighter before a serious injury occurred and most of
the time the boxer is unable to communicate. If the sealed
medical records were not needed by the end of the event, this
packet of medical records is to be returned by the paramedics to
the commission official overseeing the event, then properly
disposed by shredding as this is a viable medical file and
confidential.
9. Any hospitalization of more than one full
day represents a serious medical condition and possibly medical
liability. I propose that in the event of a hospitalized
participant, the Commission require statements from at least the
pre and post fight physician (should they be different), the
referee, the judges, the leading official of the Commission
present at the event, and all the trainers and managers of the
fighter as well as the fighter him or herself. This should then
be reviewed by the Medical Board and the Boxing Commission for
findings and recommendations.
10. Closure of medical care should be
documented at the end of the event. The physicians should not
leave unless the lead official releases them from their duty. In
order to ensure that all participant's medical needs are met, I
propose that as they receive payment for their participation, they
sign a statement that they have no further medical needs at this
time. When all the fighters have signed these releases, then the
medical staff can be excused. For practical reasons, only one
physician is needed to remain, but that can be determined by the
Boxing Commission official at the venue.
11. Religious Holidays affect availability
of physicians, especially devote followers. Ask the ringside
physicians which holiday weeks that are unavailable to minimize
the risk of being depleted of available ringside physicians for
the events to be scheduled.
12. In the event of a tragedy of a fighter
during or after a venue, the officials and the ringside physicians
need guidelines on how to handle media. The Boxing Commission
needs to contact all officials involved and provide the materials
for guidelines in dealing with complex media inquiries.
13. Physicians come to the events with a
wide range of medical equipment and supplies. Some have basic
items, whereas others bring a small "MASH' unit bag. Please note
the more prepared "MASH" unit bags are desirable, but novice
ringside physicians need to be instructed on the minimal needs
that are to be brought to the event. A list of supplies should be
established. At the Las Vegas Conference a Canadian physician
directed us to a web site which I find a good resource
www.canadianboxing.com
. The Canadians require two ringside physicians at boxing and
three ringside physicians for mixed martial arts as MMA has more
injuries and medical attention.
14. Ringside physicians need guidance in
certain medical situations. Blind in one eye, hypertension (high
blood pressure), tachycardia and or arrhythmia at rest (fast heart
rate and/or irregular rhythm, abnormal electrocardiogram (EKG),
and positive testing for HIV, Hepatitis B and C pre examination.
These guidelines can be established by the Medical Board.
