Opinion Question #5
During the review of the prefight medical physical (performed by a fighter's personal doctor), you note that he is taking Adderall, Testosterone and HGH. The fight is 4 weeks away and he states that he will stop taking all of these medications immediately. Do you....
During the review of the prefight medical physical (performed by a fighter's personal doctor), you note that he is taking Adderall, Testosterone and HGH. The fight is 4 weeks away and he states that he will stop taking all of these medications immediately. Do you....
OPINION QUESTION #4
There have been a recent increase in the number of lawsuits in boxing and mixed martial arts against commissions, doctors and promoters concerning ringside injuries and deaths. How are you (as a physician) currently covered in the event of a lawsuit?
CASE # 14
BEST ANSWER
Is this result adequate to allow him to compete?
Need More Information
Please explain your answer:
We check for Hep C AB in our state. Not sure why they ran a viral RNA?
Addendum:
Remember, a PCR measures viral load. Although the PCR can be negative, the antibody (Ab) can still be positive meaning transmission of the disease is still posible. There are some in boxing who will purposely send a PCR in place of a positive Ab knowing that a positive Ab will result in disqualification and permanent suspension. Be diligent to assure that the antibody is always negative and a positive antibody does NOT (unfortunately) convey immunity to the disease.
Is this result adequate to allow him to compete?
Need More Information
Please explain your answer:
We check for Hep C AB in our state. Not sure why they ran a viral RNA?
Addendum:
Remember, a PCR measures viral load. Although the PCR can be negative, the antibody (Ab) can still be positive meaning transmission of the disease is still posible. There are some in boxing who will purposely send a PCR in place of a positive Ab knowing that a positive Ab will result in disqualification and permanent suspension. Be diligent to assure that the antibody is always negative and a positive antibody does NOT (unfortunately) convey immunity to the disease.
CASE # 13
BEST ANSWER
Can he compete?
Yes
Please explain your answer?
If visual fields and acuity are normal, a nonfunctioning incidental pituitary lesion less than 10mm can be followed yearly and
participate without restrictions. If there are clinical suspicions for hormonal hypersecretions then an endocrine evaluation should be performed. A baseline prolactin level should be obtained, but in an incidental asymptomatic athlete, participation in combat sports does not require restriction.
Can he compete?
Yes
Please explain your answer?
If visual fields and acuity are normal, a nonfunctioning incidental pituitary lesion less than 10mm can be followed yearly and
participate without restrictions. If there are clinical suspicions for hormonal hypersecretions then an endocrine evaluation should be performed. A baseline prolactin level should be obtained, but in an incidental asymptomatic athlete, participation in combat sports does not require restriction.
CASE # 12
A bit tough to read...but it says; "Pt. is cleared for sporting activities". Note: Doctor would not sign the fighter is medically cleared to participate and crossed it out.
BEST ANSWER:
Would you let him fight with this pre-fight form as it is written?
Not Sure
Please elaborate on your answer.
Need to specifically address clearance for contact sport, including potential of head trauma. Need to have physician re-do the form and address the specifics of medical clearance as it relates to boxing or state the reason of concern. If this physician won't change the form, participant needs to have another physician complete the form. The question is this a form for a general medical evaluation or an eye exam. This fighter, based on the above recommendation is not exlcuded, but definitely not cleared from the event. More information is needed.
BEST ANSWER:
Would you let him fight with this pre-fight form as it is written?
Not Sure
Please elaborate on your answer.
Need to specifically address clearance for contact sport, including potential of head trauma. Need to have physician re-do the form and address the specifics of medical clearance as it relates to boxing or state the reason of concern. If this physician won't change the form, participant needs to have another physician complete the form. The question is this a form for a general medical evaluation or an eye exam. This fighter, based on the above recommendation is not exlcuded, but definitely not cleared from the event. More information is needed.
CASE #11
BEST ANSWER
Can this fighter compete?
Yes
Please explain your answer.
INR IS THE MORE ACCURATE INDICATOR
Addendum:
Some commissions order coagulation studies (CBC, Platelets, INR, PTT, etc.) to assess if there is a bleeding risk. Therefore, in a fighter with an elevated PT and a normal INR, one should still explore the possibility of other abnormalities such as liver disease, medication administration (i.e. Coumadin) or ETOH abuse.
Can this fighter compete?
Yes
Please explain your answer.
INR IS THE MORE ACCURATE INDICATOR
Addendum:
Some commissions order coagulation studies (CBC, Platelets, INR, PTT, etc.) to assess if there is a bleeding risk. Therefore, in a fighter with an elevated PT and a normal INR, one should still explore the possibility of other abnormalities such as liver disease, medication administration (i.e. Coumadin) or ETOH abuse.
CASE # 10
BEST ANSWER
Can this fighter compete?
Not Sure
Please explain your decision.
Yes, if his prefight vitals are normal and I would take vitals prior to the fight as well. If within acceptable range, he would be allowed to fight.
ADDENDUM: Always remember that age, other diagnosis, weight class, family history, type of medication used and other medications prescribed, need to be taken into consideration when clearing a fighter. An EKG would be helpful and a stress test may be indicated in certain circumstances.
Can this fighter compete?
Not Sure
Please explain your decision.
Yes, if his prefight vitals are normal and I would take vitals prior to the fight as well. If within acceptable range, he would be allowed to fight.
ADDENDUM: Always remember that age, other diagnosis, weight class, family history, type of medication used and other medications prescribed, need to be taken into consideration when clearing a fighter. An EKG would be helpful and a stress test may be indicated in certain circumstances.
CASE # 9A - BEST ANSWER (see below)
So the fighter with the abnormal CT scan (last week's question) was indeed sent to a neurologist for a consult. The above is his consultation. Does this change your mind? Would you let him fight now?
BEST ANSWER
Can he fight with this consultation?
No
Please explain your decision:
Although cysts less then 5cm are less likely to hemorrhage and be associated with sub dura lumin hematomas, the rate of hemorrhage is 5 times higher with trauma as compared to spontaneous bleeds. Secondly the approximation to the brainstem of this cyst and the possibility of more rapid expansion is concerning. Third, it is not known if this cyst is stable and even without symptoms, I would recommend avoiding all contact sports with a follow up MRI in 1 year to assess for potential expansion. Even with no growth in 1 year, I would encourage the boxer to consider alternative career paths or non contact sports.
BEST ANSWER
Can he fight with this consultation?
No
Please explain your decision:
Although cysts less then 5cm are less likely to hemorrhage and be associated with sub dura lumin hematomas, the rate of hemorrhage is 5 times higher with trauma as compared to spontaneous bleeds. Secondly the approximation to the brainstem of this cyst and the possibility of more rapid expansion is concerning. Third, it is not known if this cyst is stable and even without symptoms, I would recommend avoiding all contact sports with a follow up MRI in 1 year to assess for potential expansion. Even with no growth in 1 year, I would encourage the boxer to consider alternative career paths or non contact sports.
CASE # 9
BEST ANSWER
Would you let this fighter compete with this CT Scan Report?
No
Please explain your answer.
Though most arachnoid cycsts are asymptomatic and require no further treatment. Some can become symptomatic and hemorrahge causing complications. Taking blows to the head could potentially cause complications. I would not clear the fighter until neurosurgical consultation and further imaging and treatment is recommended.
Would you let this fighter compete with this CT Scan Report?
No
Please explain your answer.
Though most arachnoid cycsts are asymptomatic and require no further treatment. Some can become symptomatic and hemorrahge causing complications. Taking blows to the head could potentially cause complications. I would not clear the fighter until neurosurgical consultation and further imaging and treatment is recommended.
CASE # 8
CAN HE FIGHT WITH THIS REPORT?
BEST ANSWER:
Can he fight with this report on his physical exam?
Yes, but would drug test after the fight
Please explain your answer:
Marijuana is included in the WADA list of forbidden substances in competition. The athlete should be informed that he can incur in a doping rules violation and disqualification if he is tested positive to marijuana after a fight.
BEST ANSWER:
Can he fight with this report on his physical exam?
Yes, but would drug test after the fight
Please explain your answer:
Marijuana is included in the WADA list of forbidden substances in competition. The athlete should be informed that he can incur in a doping rules violation and disqualification if he is tested positive to marijuana after a fight.
OPINION Question # 3
Should the ringside physician have the right to stop a fight?
Currently, the ABC Unified Rules state:
2. The referee is the sole arbiter of a bout and is the only individual authorized to stop a contest.
Currently, the ABC Unified Rules state:
2. The referee is the sole arbiter of a bout and is the only individual authorized to stop a contest.
BEST ANSWERS: Conflicting Viewpoints!!!:
ANSWER #1
Should the Ringside Physician Have the Power to Stop a Fight?
No
Please explain your decision.
Stop a contest, no, not as worded. The physician is not able to fully evaluate the fighter from their seat. If there is a concern on the part of the referee or physician, the physician can ask or be asked to evaluate the fighter at the start of each round. If something occurs during a round and the referee has not paused the round for physician evaluation, all I have had to do is stand at my seat and the referee has called me up to the apron. After an evaluation, if the physician or corner feels that the fighter cannot continue, the referee is notified and the referee stops the contest. I have not seen an occasion that the referee has gone against the opinion of the physician or corner. You can only have one person in charge of a contest and each person involved in that contest must rely on the others to do their job correctly.
ANSWER #2
Should the Ringside Physician Have the Power to Stop a Fight?
Yes
Please explain your decision.
In many fights that I have been able to help at ringside the referree is unable to recognize the injuries being inflicted on the fighter whether it was from their POV or just ignorance of the nature of the beating and the impact to the fighter at that time. In most cases it has been a better view point from my side of the ring. This may not be as common at the "higher" level of competition with more experienced referrees but definitely at the amateur level.
SIDE NOTE: As a ringside physician, I have only been overruled one time in my 23 years working in boxing and MMA. I actually stopped Gatti-Ward #1 at the end of the 9th round. However, the referee allowed the fight to continue. Most people dont even know that happened!
ANSWER #1
Should the Ringside Physician Have the Power to Stop a Fight?
No
Please explain your decision.
Stop a contest, no, not as worded. The physician is not able to fully evaluate the fighter from their seat. If there is a concern on the part of the referee or physician, the physician can ask or be asked to evaluate the fighter at the start of each round. If something occurs during a round and the referee has not paused the round for physician evaluation, all I have had to do is stand at my seat and the referee has called me up to the apron. After an evaluation, if the physician or corner feels that the fighter cannot continue, the referee is notified and the referee stops the contest. I have not seen an occasion that the referee has gone against the opinion of the physician or corner. You can only have one person in charge of a contest and each person involved in that contest must rely on the others to do their job correctly.
ANSWER #2
Should the Ringside Physician Have the Power to Stop a Fight?
Yes
Please explain your decision.
In many fights that I have been able to help at ringside the referree is unable to recognize the injuries being inflicted on the fighter whether it was from their POV or just ignorance of the nature of the beating and the impact to the fighter at that time. In most cases it has been a better view point from my side of the ring. This may not be as common at the "higher" level of competition with more experienced referrees but definitely at the amateur level.
SIDE NOTE: As a ringside physician, I have only been overruled one time in my 23 years working in boxing and MMA. I actually stopped Gatti-Ward #1 at the end of the 9th round. However, the referee allowed the fight to continue. Most people dont even know that happened!
CASE # 7
Can this fighter compete with this lab report?
BEST ANSWER
Can this fighter compete?
Not sure
Why did you make that determination?
A decision cannot be based on the CPK result alone. It is very likely elevated from muscle damage that occurs during training. If the rest of the physical exam is normal, it should not be a problem. The doctor may want to obtain an EKG to look for cardiac changes or a step stress test, but realistically, without any symptoms or history of chest pain, seizures, muscle diseases, thyroid disorders, recent surgeries, or medications, there should not be a problem. As a side note, with repeated IM injections and associated excessive exercise, the Commission may want to evaluate the fighter for steroid abuse (if there are other positive signs.)
Not sure
Why did you make that determination?
A decision cannot be based on the CPK result alone. It is very likely elevated from muscle damage that occurs during training. If the rest of the physical exam is normal, it should not be a problem. The doctor may want to obtain an EKG to look for cardiac changes or a step stress test, but realistically, without any symptoms or history of chest pain, seizures, muscle diseases, thyroid disorders, recent surgeries, or medications, there should not be a problem. As a side note, with repeated IM injections and associated excessive exercise, the Commission may want to evaluate the fighter for steroid abuse (if there are other positive signs.)
Opinion Question # 2
BEST ANSWER:
Should female fighter's undergo a yearly gynecologic exam to be cleared to compete?
Should female fighter's undergo a yearly gynecologic exam to be cleared to compete?
NO
"The female competitor should have this done annually but not as a requirement to fight....for any concerns of anovulation and considering the fighters future plans for conception maybe she should get her care done as all females should."
NOTE: (In the study ‘Medical survey of female boxing in Italy in 2002-2003’, Br J Sports Med 2005;39:532-536) it states:
No lesions to the breast area were found, nor were there any reports of abdominal or pelvic problems related to fighting. During competition and in the days following, no boxers reported acute symptoms or severe conditions requiring hospital admission.
Similarly, no major lesions were reported from the prospective study. Two benign tumours and one ovarian cyst were found – with no suggestion that these were caused by boxing.
OPINION:
Therefore, it is wise to recommend that a yearly screening (including a pelvic ultrasound) be performed, but not necessarily as a requirement to compete. MMA may be more of an issue as there is a higher risk of pelvic injuries due to kicks and knees to the groin area. Each commission should consider this when determining if a yearly gyn exam should be required.
"The female competitor should have this done annually but not as a requirement to fight....for any concerns of anovulation and considering the fighters future plans for conception maybe she should get her care done as all females should."
NOTE: (In the study ‘Medical survey of female boxing in Italy in 2002-2003’, Br J Sports Med 2005;39:532-536) it states:
No lesions to the breast area were found, nor were there any reports of abdominal or pelvic problems related to fighting. During competition and in the days following, no boxers reported acute symptoms or severe conditions requiring hospital admission.
Similarly, no major lesions were reported from the prospective study. Two benign tumours and one ovarian cyst were found – with no suggestion that these were caused by boxing.
OPINION:
Therefore, it is wise to recommend that a yearly screening (including a pelvic ultrasound) be performed, but not necessarily as a requirement to compete. MMA may be more of an issue as there is a higher risk of pelvic injuries due to kicks and knees to the groin area. Each commission should consider this when determining if a yearly gyn exam should be required.
Opinion Question # 1
Should Nurses (APRN) or Physician Assistants (PA) be able to perform the pre-fight physical exam and clear a fighter to compete without a physician's supervision?
BEST ANSWER:
Should ancillary professionals be able to clear a fighter without physicians supervision?
Only with a physician's signature
Please explain your decision.
At least in my state (Florida) ARNP or PA cannot practice without the supervision of a physician. So a physician's signature would be required for clearance. I am not sure if there are states where they are allowed to practice independently. In such states they could clear the fighter, but who is assuming the liability if something happens during the bout? At ringside you will have physicians. So If ARNPs or PA are perfomring and clearing atheltes I would suggest that the ringside physician for the evening review the exam and state if the fighter is indeed clear to fight or not.
Addendum:
It seems that state and tribal law may dictate some of the regulations as well. However, almost every response I received believed that only physicians (MD or DO) should be performing these exams.
Should ancillary professionals be able to clear a fighter without physicians supervision?
Only with a physician's signature
Please explain your decision.
At least in my state (Florida) ARNP or PA cannot practice without the supervision of a physician. So a physician's signature would be required for clearance. I am not sure if there are states where they are allowed to practice independently. In such states they could clear the fighter, but who is assuming the liability if something happens during the bout? At ringside you will have physicians. So If ARNPs or PA are perfomring and clearing atheltes I would suggest that the ringside physician for the evening review the exam and state if the fighter is indeed clear to fight or not.
Addendum:
It seems that state and tribal law may dictate some of the regulations as well. However, almost every response I received believed that only physicians (MD or DO) should be performing these exams.
Case # 6, June 10, 2014
Can this fighter compete?
Case # 5 - June 2, 2014
Can This Fighter Compete?
Case # 4 - May 27th, 2014
Can This Fighter Compete?
CASE # 3 - May 20, 2014
Can This Fighter Compete?
VOTING IS NOW CLOSED
BEST ANSWER -
Would you let him fight with this report?
No
Why did you make that decision?
A neurologist should define the minimal changes on the MRI, examine the fighter and then clear if
indicated.
BEST ANSWER -
Would you let him fight with this report?
No
Why did you make that decision?
A neurologist should define the minimal changes on the MRI, examine the fighter and then clear if
indicated.
CASE # 2 - May 16, 2014
Can This Fighter Compete?
CASE # 1 - May 11th, 2014
CAN THIS FIGHTER COMPETE WITH THIS LABORATORY RESULT?
