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Boxer Safety

Reducing System Errors in the Ring

Sethi, Nitin K. MD, MBBS, FAAN

doi: 10.1249/JSR.0000000000000236
Invited Commentary

Department of Neurology, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, NY

Address for correspondence: Nitin K. Sethi, MD, MBBS, FAAN, Comprehensive Epilepsy Center, New York-Presbyterian Hospital, Weill Cornell Medical Center, 525 East, 68th Street, New York, NY 10065; E-mail:

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Ringside medicine and the care for boxers are challenging. Timely identification of injuries, especially traumatic brain injuries and concussions, is difficult during boxing matches where every punch is thrown intending to knock out the opponent. The referee, boxing commission inspectors, and ringside physicians must work as a team to reduce catastrophic injury and improve boxer safety.

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Systemic Failures in Medicine and Ringside

Medical errors can injure and at times kill patients. Errors occur in all practice settings: in both large and small hospitals around the world. Most of these errors are unintentional but preventable. In 1999, the Institute of Medicine published a report titled, “To Err is Human,” which described a staggering number of patient deaths due to medical errors and laid out a comprehensive strategy to reduce preventable medical errors (3). Most of the identified errors were systemic failures in the practice of medicine. A systemic failure may be simply defined as a failure due to a single flaw or several flaws in the work flow or structure. Systemic failures in medicine are often embedded in the work culture, are predictable if the systems are critically reviewed, will recur if the flaws are not identified and rectified, are difficult to prevent in every circumstance (every system, no matter how well designed, can and will fail at some point), and often involve human errors. The term systemic failure is frequently used in political and financial circles when things go wrong like the recent stock market crash in America, which was blamed on several systemic failures within the banking system.

Medicine however is different. Systemic failures in medicine can be measured in lost lives and limbs, and medical errors corrode the public trust in physicians and the health care infrastructure. When failures occur in medicine such as medication errors (the patient gets the wrong medication or a wrong dose of the correct medication) or surgical errors (the surgeon operates on the wrong patient or the wrong limb of the correct patient), the individual physician (captain of the ship) is held responsible. However, a close review of each case shows that the adverse outcome is precipitated, activated, or amplified by a wider systemic failure or failures.

Ringside medicine when practiced in the context of boxing is no different. Deaths have occurred in the ring, which were often preventable. When a boxer dies in the ring, the individual referee, the ringside physicians, the commission officers, or all are held responsible. The media is quick to name a culprit, and social media spreads the horrific images far and wide. “Why was the fight not stopped?” is the question most commonly asked. The cry to “ban the barbaric sport of boxing” is raised. The term “human cockfighting” was used by U.S. Senator John McCain to describe mixed martial arts.

So how do we avoid these tragic errors in boxing? How do we make boxing safer? A close review of cases where a boxer has died in the ring reveals that in boxing too, fatalities occur when an individual referee, commission inspector, or ringside physician’s failure is precipitated, activated, or amplified by a wider systemic failure. In most cases, these failures are preventable if there is effective communication among the referee, the commission inspectors, the ringside physicians, the boxer, and his corner team.

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Interaction between the Commission Inspector and the Ringside Physicians

The commission inspector shares prime responsibilities with the referee to enforce the rules of the commission and to ensure that the bout is conducted in a fair, orderly, ethical, and safe manner. The ringside physicians are entrusted with the health and safety of the two contestants. The ringside physicians first meet the boxer at the time of the weigh-in when they conduct physical examination; this typically takes place 24 h before the bout.

The inspectors, on the other hand, meet the boxer and corner staff at the venue a few hours before the scheduled bout and remain at the boxer’s side until the fight is finished and the physician has conducted a postbout examination. Because the boxer is under the inspector’s close observation from the time of his or her arrival at the venue until the fight is over, the inspector becomes the eyes and ears of the ringside physician(s). The inspector is expected to immediately report any changes or abnormalities observed during the prefight wrapping and gloving, such as any swelling or deformity of the boxer’s hands or any other orthopedic injury involving the shoulders or the knees, to the ringside physician. This circumstance usually occurs when the boxer is injured in the 24-h period between the physical examination (at the time of the weigh-in) and the fight itself. Any other obvious medical issues such as dehydration or a fresh laceration, if noticed, should be brought to the physician’s attention at the venue.

During the fight, the inspector and the ringside physician should talk to each other between rounds to see if there are evolving health concerns in one of the boxers. If a knockout (KO) occurs during the bout, it is the inspector’s responsibility to secure the ring and make way for the physician to enter the ring to tend to the injured boxer. The route to the dressing room and the ambulance access also need to be secured for potential evacuation from the ring. The stabilization of the boxer is best left to the physician.

Postfight, in the dressing room, the inspector helps to ensure that the physician has time and space to examine the boxer. The boxer should not be allowed to leave the venue without full medical clearance from the ringside physician.

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Interaction between the Referee and the Ringside Physicians

Many boxing commissions recognize the referee as the sole arbiter of a bout and the only individual authorized to stop a contest. Very few referees have a medical background or formal knowledge of traumatic brain injury. Because a referee’s medical knowledge is limited, he and the ringside doctor need to act as a team to optimize the boxer’s safety.

Referees should be skilled in recognizing concussions in the ring, especially of the more subtle grades 1 and 2 when the boxer is “out on his feet,” unable to defend himself, looks dazed, staggers around the ring, rests on the rope but does not experience loss of consciousness, is confused, does not remember the round, walks to the wrong corner after the bell, or hits out at the referee. When in doubt, the referee should not hesitate to call a time out and walk the injured boxer over to the ringside physician for a formal assessment. Conversely, the ringside physician should not hesitate in voicing concern about an injured boxer to the referee. Although ideally this should be done between rounds, if the need arises, the ringside physician should step up to the ring apron and call a time out. The bout is then stopped and the referee walks the injured boxer to the physician for evaluation.

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Making Boxing Safer

The referee, inspectors, and ringside physicians, although working independently, must cooperate and integrate their roles to improve the bout safety systems. For this to occur smoothly, communication is the key. Formal introductions in the dressing room before the bout help establish trust and confidence. This time is also an opportunity for the referee, inspector, and physician to share health concerns about a particular boxer in an upcoming bout. The role of systems process checklists, time outs, and medical safety protocols cannot be overemphasized (1). The ringside physicians should follow established trauma protocols when evaluating an injured boxer. No boxer should be discharged from the venue with a Glasgow Coma Scale less than 15. When in doubt, the boxer should be transported via ambulance to the nearest level I trauma center (24-h in-house coverage by general surgeons and prompt availability of care in specialties such as orthopedic surgery, neurosurgery, anesthesiology, emergency medicine, radiology, internal medicine, plastic surgery, oral and maxillofacial, pediatric, and critical care). The health and safety of the boxer should always be the prime concern of boxing officials and medical providers. The referee, commission inspectors, and ringside physicians working as a team help to ensure boxer safety (Table). Yes, boxing can be made safer with strict attention to the safety systems processes (2)!



N.K. Sethi serves as an associate editor in The Eastern Journal of Medicine, and ringside physician to the New York State Athletic Commission (NYSAC). The views expressed are his and do not represent the views of the NYSAC.

The author has no additional data to share and does not have any financial disclosures.

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1. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Macmillan Publishers, 2009.
2. Sethi NK. Boxing can be made safer. Ann. Neurol. 2013; 73: 147.
3. Stelfox HT, Palmisani S, Scurlock C, et al. The “To Err is Human” report and the patient safety literature. Qual. Saf. Health Care. 2006; 15: 174–8.
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