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Tuesday, November 13, 2007
Ring tragedy from a doctor's perspective

By Dr. Margaret Goodman
Special to ESPN.com

It's been 25 years since Duk Koo Kim died after fighting Ray Mancini on national television. Kim collapsed at 19 seconds of the 14th round. He received emergency surgery to remove a large blood clot on the brain's surface, but died five days later.

The facts surrounding the Kim-Mancini bout are similar to those of any ring death. The fight was brutal, but so are many bouts that don't end in calamity. Defenders of the sport point to boxing's "inherent danger" as a vague absolution.

Regulatory changes have improved overall safety, but have done little to change the frequency of fatalities.

Duk Koo Kim
Korean lightweight Duk Koo Kim was carried out of the ring unconscious on a stretcher enroute to Desert Spring Hospital. There, doctors found bleeding in his brain.
In 2007, West Virginia University neurosurgeons Vincent J. Miele and Julian E. Bailes performed a computer-assisted video analysis of thousands of rounds to determine predictive factors for fatal bouts. They factored in a fighter's age, ring history, weight class, stance, country of origin and Compubox's computerized punch scoring system along with video analysis. Fights were separated into three categories: The first was "average bouts," which consisted of 4,000 televised fights that did not result in significant neurological injury; the second was the "classic" group, designated as "Fight of the Year" by the media; the last was the "fatal" group, in which a participant died.

The investigators found little difference between classic and fatal matches. Furthermore, fighter inactivity between bouts, history of KOs and TKOs, or loss statistics was not predictive.

This is valuable information, but many boxing tragedies don't occur in the toughest fights.

I was one of the ringside physicians when Pedro Alcazar fought Fernando Montiel at the MGM Grand Garden in June 2002 for the WBC super flyweight title. The fight was stopped in the sixth round after a flurry of body shots rendered Alcazar helpless. Alcazar was deemed healthy after the bout but collapsed two days later in his hotel room.

Speculation abounded whether he had trouble making weight, came into the fight dehydrated, suffered an injury in training or had a predisposing medical condition.

Nothing turned up. In fact, Alcazar's autopsy showed a small amount of bleeding with severe brain swelling. This is in sharp contrast to the majority of boxing deaths, like Kim's for instance, where there is immediate severe bleeding on the brain's surface.

Good can come from bad, and there have been many positive changes in boxing on the heels of ring tragedies.

Following the Kim bout, the Nevada State Athletic Commission's Dr. Edwin Homansky lobbied the major sanctioning organizations to change championship bouts from 15 to 12 rounds. It wasn't that more deaths occurred in these rounds, but after a careful review of the Kim-Mancini bout and other 15-round contests, it was revealed that fighters just threw head shots and maintained virtually no defense in Rounds 13 through 15. Homansky and the NSAC also prompted changing the number of ring ropes from four to five to prevent fighters falling from the ring and through the ropes.

Soon after Alcazar's death, Nevada began requiring pre-fight brain MRI testing to not only serve as a baseline, but also insure that a fighter didn't enter the ring with a potentially lethal condition.

In preventing serious ringside injuries, boxing needs to limit predisposing factors.

Undisclosed or ignored injuries top the list. Whether a boxer wears headgear or not, the brain is at risk from any head blow. Either to refrain from showing weakness, or to avoid canceling a scheduled bout, fighters often ignore symptoms such as a headache, dizziness, nausea, memory loss or balance difficulties that may signify a serious head injury.

It's likely that junior middleweight Stephan Johnson suffered an undiagnosed cerebral hemorrhage (brain bleed) seven months prior to his fatal fight against Paul Vaden in 1999 in New Jersey. Several commissions missed this fact and it's unknown if Johnson had neurological complaints going into that fight.

Predisposing factors relating to boxing fatalities

Causes
Profound rapid weight loss
Dehydration
Repeated head blows
Brain abnormalities
Second Impact Syndrome (ignored seemingly minor head injury followed by a second one resulting in brain cell death)
Undisclosed injuries
Medical history including high blood pressure, heart disease, diabetes, bleeding disorder
Advancing age
Medications that induce bleeding risks or blood pressure
Inappropriate weight class
Alcohol
Steroids
Erythropoietin (EPO)
Other elements that can increase ring death risk include rapid weight loss and dehydration, which slow the reflexes; fighting in the wrong weight class; inadequate medical suspensions or time off between contests; medications such as aspirin or Motrin, which limit the blood's ability to clot; stimulants that increase blood pressure and heart rate; alcohol or steroids, which limit blood clotting; EPO (erythropoietin), which can increase blood thickness and precipitate a stroke or heart attack; and advancing age that shrinks the brain and stretches the tiny vessels connecting the brain to its protective covering that can tear when the head is struck.

Ring tragedies can become a thing of the past through proper preparation.

Every commission should require at least two trained physicians at ringside with emergency equipment and paramedics to administer life-saving treatment. Ideally, extensive post-fight examinations should be administered as well, to ensure the fighters are triaged properly before being allowed to return home. Documentation should be forwarded that guarantees all medical forms are legitimate and performed by acceptable personnel.

Matches must take place in venues that are accessible to emergency personnel and a nearby trauma center. "The Golden Hour" should be a term boxing commissions, the fighters, personnel and even fans should familiarize themselves with. It's that one hour in which a majority of critically injured trauma patients can be saved if definitive surgical intervention is provided.

A boxer with post-fight complaints, irrespective of whether he won, lost or was knocked out, should be transported to a Level 1 trauma center. This type of facility has 24-hour access to every medical specialty, including a brain surgeon. If fights take place in outlying areas, a rescue helicopter should be on hand for transport.

In the event of a death, the commission should conduct inquiries that include statements from all who were present, along with a detailed review of the fight film, medical protocols and licensing paperwork.

Unfortunately, too few are willing to go these lengths for fear of litigation or acknowledgement that something could have been done better. Instead, we accept an occasional tragedy and do everything possible to limit the discussion.

Boxing can take a lesson from NASCAR, which is infinitely more proactive in protecting its athletes through extensive testing and research.

Formula One and NASCAR currently use the Delphi earpiece sensor system (ESS) to measure the effects of a crash on a driver's head and neck. Researchers have proposed placing the device in a fighter's mouth guard because the data could be used to determine if an athlete's brain has exceeded an appropriate limit of force inflicted on it, and a competition could be stopped. This type of device could save lives.

It's simple to say boxing safety comes first, but the proof lies in limiting the predisposing factors, using only qualified ring officials, thorough medical examinations, adequate medical suspensions, educating fighters regarding serious signs and symptoms of a head injury, and much-needed research. If boxing does its job, fatalities like that of Duk Koo Kim will all but disappear.

Dr. Margaret Goodman, who is a former Nevada State Athletic Commission Medical Advisory Board Chairman and Chief Ringside Physician, contributes regularly to The Ring magazine.