boxing and concussion

Monday, July 28, 2014

For most of the amateur boxers at the Glasgow Commonwealth Games this week, something was missing. As they eyed their opponent across the ring, the only protective gear seen was on their fists. The helmets presumably worn to protect their brain were gone, a decision made by the sport’s ruling body, the International Boxing Association. It seems that their unpublished research found that concussion rates go down when boxers do not wear protective head gear. Presumably, wearing head gear allowed fighters to lean into their opponent and take more blows to the head. There is controversy in this decision, with Dr. Charles Butler the chairman of the IBA medical commission and the president of USA Boxing supporting his unpublished research, while others in the medical community believing that the IBA has made an error in removing head gear from the boxers.

boxing image

The purpose of helmets in sport has been blurred somewhat and understanding anatomy may help explain some of the controversy that boxing has invited upon itself. The brain sits within the skull, but it is not a tight fit. When the head is hit, there is a slight delay between skull and brain acceleration, allowing the brain to move within the skull and bounce back and forth against the inner bony walls of the skull. A direct blow to the head is not necessary to cause damage; the head being shaken is enough to rattle the brain. The helmet is meant to prevent skull fractures, facial fractures and lacerations. These injuries can be associated with intracranial bleeding (bleeding within the skull) like subdural and epidural hematomas. The helmet however, does not prevent the concussion type injuries where the brain is shaken and there is no obvious outward damage. Even CT scanning of a concussed brain may be structurally normal. It may take imaging with special MRI or PET scan to show brain damage on a function level. For that reason concussion is a clinical diagnosis.

Loss of consciousness is not required to make the diagnosis of a concussion and the initial symptoms may be very short lived. The longer term consequences may take hours or longer to show themselves and headache, concentration and balance problems may take weeks or more to resolve. On the football field, there are teammates and coaches who can assess the mental status of a potentially concussed player, but in the boxing ring, there may be a delay in recognizing the injury. In football, soccer, basketball and other team sports, a concussion assessment takes many minutes on the sideline before the decision is made to return to play. When a boxer is knocked down, there may be only a few seconds taken by the referee.

In boxing, the head is the target for most blows. As in football and baseball, the helmet is meant to prevent broken bones (fractures), but present technology does not prevent the brain from being shaken within the skull. The removal of headgear may make boxers more wary and change the style of the sport, but the goal for winning remains the same, to inflict a concussion upon your opponent. It seems difficult to understand the position of the IBA medical commission that boxing’s goal will be altered by removing protective gear. The sport has given us the term dementia pugilistica, being punch drunk, likely the equivalent brain injury of chronic traumatic encephalopathy in football due to repeated blows to the head.

Perhaps after these Commonwealth Games and the Rio Olympics, the IBA will have more data to show that arbitrarily removing a piece of safety equipment was the way to go. While head gear may not prevent concussions, they will decrease the risk of facial fractures and lacerations, especially around the eye. It might have been wiser to have the IBA and Dr. Butler’s research and data published and allow the scientific community the opportunity to make its own recommendations, but it seems unreasonable that amateur boxers be used as guinea pigs while the answer is yet unknown.


Image attribution: Andrej Isakovic, Getty Images


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putting you to sleep

Monday, July 21, 2014

Pitcher CC Sabathia could not sleep at night, worried that he might need significant knee surgery that might end his career. After seeing the team orthopedic surgeon and discussing options, microfracture surgery which might cause him to miss two seasons, was not needed. Masahiro Tanaka, another Yankees pitcher with elbow troubles, sought opinions from three different orthopedic doctors before deciding not to have Tommy John surgery to repair an ulnar collateral ligament injury. Every day, thousands of people seek second opinions to be reassured that a planned surgery is appropriate. Every day, people forget that the surgeon is only one part of the operating team.

Most people will not know the name of the anesthesiologist assigned to put them to sleep and perhaps more importantly, to wake them up. On the assigned day of an operation, the patient and family show up to the hospital or surgical center and begin the pre-op process, where nurses assess and prepare the patient for their procedure. Eventually, an anesthesiologist or nurse anesthetist shows up at the bedside, introduces themselves and begins their evaluation. Odds are, they are randomly assigned that day to the surgeon but hopefully, they have reviewed the medical record the day before. For patients who are hospitalized, that visit may take place the evening before. But few people consider who that anesthesiologist might be.

Anesthesia is not what it used to be. Depending upon the surgery, the patient may have options to choose different types of anesthesia, whether it be local, regional or general. Most people have had a local anesthetic where medication is injected into a small area of the body. From laceration repair to a dental filling, the purpose is to block pain fibers but touch, pressure, vibration and movement sensat8ons are all intact. For that reason, most people feel stuff under local; the goal is to have little or no pain.

Regional anesthesia blocks whole sections of the body. The anesthesiologist can inject medications into the spinal canal area like an epidural used during labor or C -section, or inject medication into a vein to anesthetize a single limb. It’s easy to talk about, but there is technical skill needed to get the anesthetic into the right place, in the right amount and to monitor the patient to make certain complications don’t occur and the anesthetic wears off at the proper time.

General anesthetic is the one often seen in television dramas where the patient is sedated and sometimes paralyzed so that an operation can occur. Not all operations require a patient to be paralyzed but should that be the case, the skill of the anesthesiologist is even more important. The paralyzed patient needs somebody to breathe for them and to monitor and support their vital signs. This is where the critical part of this critical care specialty comes to bear and why the pre-op visit is so important.

Not every patient is young and healthy and the patient with heart disease, lung disease, diabetes or on dialysis, all pose a challenge to the anesthesiologist. Pick a disease or illness and it can cause an anesthetic complication. Every patient has a unique set of circumstances that will affect the choice of anesthetic and the type and amount of medications used. Not everybody qualifies for anesthesia; patients can be too sick or too complicated so that the risk of dying during the operation or postop course is greater than the benefit that surgery might offer.

History and physical are the important tools for that pre-op evaluation. Past medical history is obvious, but not so with family history where a relative who had a bad anesthetic outcome might be the clue that it could be hereditary. Medication history is more than prescriptions meds but also needs to include over the counter medications and herbal remedies that might interact with the anesthetic. Physical exam might uncover an issue that would increase the risk. Showing up the day of an operation with a cold or other infection might be enough to have the procedure postponed. For the anesthesiologist, it’s all about controlling risk and minimizing disaster. Heart attack, stroke, pneumonia, vocal cord damage from being intubated, temporary and not so temporary confusion are some of the anesthetic risks independent of what the surgeon is doing.

The anesthesiologist is one of the invisible doctors in medicine, where their work is invaluable to their colleagues and their patients but most people don’t know their names or qualifications…nor do they seem to care. Radiologists who look at x-rays rarely touch patients but their opinions drive diagnosis and treatment decisions. Pathologists look at tissue samples and cells to make a variety of diagnoses including cancer/not cancer. Their world is set apart from touching patients, yet their skill is invaluable.

So back to Mr. Sabathia and Mr. Tanaka. Surgeons sought by elite athletes often have their own team, from anesthesia, to scrub nurses to physical therapists. Regular patients often search the country for the surgeon but leave picking the rest of the team to chance. Credentialing and peer review committees hold doctors, including anesthesiologists, accountable to maintain their knowledge and skills. It’s a stressful time when the doctor shows up at the bedside before surgery. Still, it might be nice to remember their name…they may hold your life in their hands.

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