Medical

THE MEDICAL MANAGEMENT OF SERVICE BOXING

Introduction

1. Boxing, like many other sports, carries sport-specific risks of injury to participants [1]. Medical personnel have a part to play in mitigating the risks by providing appropriate boxing medical examinations and ringside support to Service Boxing events. In many units Service Boxing is an established part of their military life and Defence Medical Services (DMS) personnel may be requested to support these events.

Aim

2. This leaflet defines and explains the application to Service boxing of the governing International Boxing Association (AIBA) Regulations 2015 [2] by medical staff across the DMS.

Scope

3. This policy applies to Ministry of Defence (MOD) sponsored events where appropriately trained and clinically current medical personnel are authorised by their medical Chain of Command (CoC) to carry out the medicals and/or ringside cover as part of their military duties.

4. This policy only applies to non-MOD sponsored events when medical personnel are directed by their CoC to provide medical cover as part of their MOD duties in support of military boxers.

5. It is to be read in conjunction with the AIBA Regulations2 and the Medical Commission of the AIBA Medical Handbook 2013 [3].

Background

6. The supervision of Service boxing is carried out by a team of people including single Services (sS) boxing association’s officials, CoC and medical personnel. Medical personnel contribute within this team by performing some or all of the following roles:

a. Undertaking boxing medical examinations.

b. Providing the ringside medical support at boxing events.

Boxing Medical Examinations

7. All clinically current MOD doctors, including uniformed Medical Officers (and General Duties Medical Officers (GDMOs)), MOD-employed Civilian Medical Practitioners (CMPs) and contracted civilian doctors, including locums, working in Defence Primary Health Care (DPHC) medical facilities, or doctor with access to the boxer’s electronic Integrated Healthcare Record (eIHR) may [4] perform routine boxing medicals, with reference as necessary to the details within this leaflet and the international governing regulations.

8. Boxing Medical Examinations in the Services are required in the following circumstances:

a. Annual boxing medical examinations. The medical examination is to assess whether the individual is medically fit to spar and/or box. The examination is valid for one full year from the date that the medical is completed [5]. They are required by the following:

(1) Aspirant boxers who are new to Service boxing and have no previous boxing experience must have their first medical done at least 10 clear days before their first bout as this is the statutory minimum spar training period.

(2) Boxers whose previous annual boxing medical examination is about to expire.

(3) Boxers whose period of suspension for injury has concluded; passing this medical then re-qualifies the boxer for a further one year from the date of this medical unless suspended again following further injury.

b. Pre-bout Medical. Pre-bout medicals are carried out on the day of the bout – at a time between the weigh-in and bouts-start – to be agreed between doctor and event Supervisor.

c. Post-bout Medical. A post-bout medical check must be carried out on all boxers at the conclusion of each bout.

Annual boxing medical examinations

9. The AIBA Medical Handbook and the Guidance Notes for Doctors Performing Boxing Medical Examinations (Annex A) should be used for reference and guidance for carrying out annual boxing medicals.

10. Annual boxing medical examinations are to be documented on the eIHR using the relevant boxing medical template that can be found within the boxing protocol. The template provides the structure to record the following:

a. Discussion and explanation of the sport-specific risks of boxing and obtaining the aspirant boxer’s informed consent to accepting these, in particular the risks of brain injuries.

b. Satisfactory status as an un-coerced volunteer to participate in boxing as all Service boxers must be volunteers.

c. The absence of any history of conditions that must prevent boxing or on which seeking Subject Matter Expert’s (SME’s) advice is mandated.

d. Normal examination findings (run-up examination tests and doctor’s examination).

e. A pass, a permanent fail or a temporary fail pending SME advice [6].

11. The Statement of Results of Annual Medical and the Informed Consent to Participate in Service Boxing (Annex B) will be auto-initiated by the eIHR protocol and is to be completed, printed, date-stamped and signed by the doctor and the boxer.

12. The completed dual-signed Annex B is to be scanned onto eIHR as an attachment to the consultation showing the boxing medical. Two A5 hard copies are given to the boxer to take to their coach, one to be retained in the back of the Boxer’s Record Card (BCR1) and one to be sent by the coach to the sS Boxing Association Secretary for annual registration action to be taken.

13. The eIHR protocol sets the validity of this medical to one year.

14. At a post-suspension renewal annual medical the doctor is to make a reassessment before allowing resumption of sparring and boxing. The doctor will need to endorse the BCR1 that a post-suspension renewal annual medical has been passed, and issue a renewed Annex B in the course of updating the eIHR record. Again, the eIHR protocol will reset the date for the annual boxing medical requirement to one year ahead.

Pre-bout Medical

15. Pre-bout medicals are to be done on every boxer on the day of the bout at any time between the weigh-in and the start of the boxing; timings to be agreed between the doctor and Supervisor.

16. Pre-bout medicals are best done at the Medical Centre with access to the eIHR, ideally (but not necessarily) by the same doctor who will be the Ringside Physician for the contest later. However, they may be done at the boxing gym, in a room suitable for medical examinations with all necessary paperwork provided.

17. When boxers attend a pre-bout medical, they must present the doctor with the following:

a. Their MOD90 Identification Card.

b. BCR1 with copy of Annex B showing their most recent annual medical stapled into the back.

c. Mouthguard [7]. The doctor is to check that the boxer has an adequately-fitting mouthguard that does not drop out of the boxer’s mouth when they open it wide. Mouthguards must not red-coloured. A boxer with a poorly fitted or wrong colour mouthguard is to be referred to the supervisor. Mouthguards must be worn by boxers during all boxing bouts and sparring.

d. A completed and signed Pre-bout Medical Examination Questionnaire (Annex C).

18. The pre-bout medical consists of a check of fitness to box that day and confirmation of the full annual medical that was performed earlier.

Post-bout Medical

19. Post-bout medicals will be covered at Paragraphs 38+39 under the Ringside Medical Cover section below.

Ringside Medical Support

Ringside medical personnel requirements

20. The ringside medical team must consist of a Ringside Physician [8] who must be a doctor who is competent to manage the airway of an unconscious boxer and in date for Advanced Life Support (ALS) or other relevant Pre-Hospital Emergency Care (PHEC) qualification. The team must also include at least one additional airways-management-competent paramedic.

21. Medical Officers (MOs) must be post Certificate of Completion of Training (CCT) before acting independently at ringside. General Duties Medical Officers (GDMOs) may attend for training/experience but it is not suitable for a post-graduate trainee, regardless of their speciality or stage of training, to fulfil any part of the requirement of the Ringside Medical Team [9] .

22. Advice on suitable ALS and/or PHEC courses to attend to improve/refresh a doctor’s airways management skills for ringside work should be sought from the Defence Deanery and/or SMO CSBA [10].

23. Ringside medical support should be found from uniformed resources whenever possible but when such cannot be found, it may need to be bought in from external sources and funded by the sS boxing association. In these cases it is especially important that the Ringside Physician or most experienced member of the ringside medical team liaise closely with SMO CSBA to ensure that the medical requirements are fulfilled.

24. Civilian Medical Practitioners (CMPs) who wish to volunteer to provide Ringside Physician cover to boxing may do so with consent from their Senior Medical Officer (SMO) or Regional Clinical Director (RCD) as appropriate [11].

25. Consideration of the local neurosurgical capability must also be taken into account. Before any boxing bout, it is a standard good practice requirement for the Ringside Physician (or a delegated member of their team) to notify the nearest neurosurgical unit of the fact that boxing is to take place.

Ringside medical equipment requirements

26. All necessary resuscitation and all other necessary equipment must be available ringside for the boxing to proceed. It is also imperative that any kit designated for boxing use must not limit unit primary activity [12]

27. This equipment requirement includes the following:

a. Pre-positioned ringside ambulance [13].

b. Airways management kit including different types of airways, suction, oxygen etc.

c. A scoop (or a spinal board if no scoop available) to immobilise and move an unconscious boxer under the ropes and out of the ring.

d. Basic doctor’s kit such as stethoscope, auriscope and ophthalmoscope etc.

e. Equipment to manage any lacerations that can be managed at the event to obviate a trip to A+E for the injured boxer and their coach.

Boxing overseas

28. Service boxing may only be undertaken outside the United Kingdom (UK) where arrangements for hospital care have been judged to be adequate by the Service medical authorities[14]. All requests to organise boxing outside the UK are to be staffed with ample notice to SMO CSBA who will seek authorisation from Headquarters Surgeon General (HQ SG).

29. Service boxing on deployed operations and on exercises is not normally permitted but a unit wishing to seek a waiver must do so by contacting the SMO CSBA10. SMO CSBA will liaise with HQ SG and relevant boxing association to consider all the circumstances on a case by case basis.

Planning Ringside Medical Cover

30. Ringside medical cover (doctor and paramedics/ambulance support) should primarily be provided from Service resources whenever possible, but this may not always be available. If service ringside medical cover to a scheduled event cannot be found by one calendar month ahead of the event date, the medical lead must contact the relevant sS boxing association so that arrangements for buying in contracted ringside cover can be activated.

Ringside Medical Support Delivery

31. It is appreciated that the ringside medical support element may raise concerns for some doctors. As this is strategic policy it does not cover the comprehensive tactical details and any doctor who requires amplification or assurance on any aspect of boxing should seek advice from SMO CSBA.

32. Before the start of the boxing, the Ringside Physician must satisfy themselves that all the necessary kit (as above) is available and working correctly and that the medical team can provide the necessary level of medical support including ambulance and correctly trained personnel. A pre-bout team briefing led by the Ringside Physician must take place to clarify exactly whose role is what within the team, which is particularly important when there is a mix of civilian and military personnel within the team. If any concerns arise, these are immediately to be raised and discussed with the Supervisor. The Ringside Physician must be able to make a decision, before the boxing commences, that they are content and that the team can provide the necessary medical support.

33. All boxing matches must have a Ringside Physician present at the ringside at all times; if the Ringside Physician is busy attending to a boxer post-bout, the next bout has to be delayed. It is good practice for the doctor to advise the boxing supervisor [15] if such delays are going to be more than brief.

34. If a boxer is injured, the referee decides what to do in the following circumstances:

a. If a boxer is down [16], the Ringside Physician will normally be invited into the ring promptly, with medical assistants as appropriate, to deal with airway management, etc.

b. If the referee wishes the Ringside Physician’s advice, the referee can invite the Ringside Physician to assess the boxer in the ring. The AIBA rules2, 3 clarify that when the referee asks the doctor for advice on a boxer, the doctor’s advice is binding on the referee and supervisor. Examples of such requests include a nose bleed that may indicate an underlying nasal fracture, lacerations or after an 8 second count to assess for concussion and fitness to continue or not.

c. When the referee wishes to ask the Ringside Physician to check a boxer before a further round, this is not normally done during the one minute rest period when the boxer must focus on his coach’s briefing, but instead the referee will restart the boxing, then at once temporarily stop it and ask the Ringside Physician to assess whatever it is that is causing concern, and then take the advice given, as above.

35. If at any stage, a member of the medical team has concerns that the referee should be seeking medical advice but is not doing so, they should raise their concerns initially to the Ringside Physician. If the Ringside Physician agrees [17] with these concerns then they will raise them to the Supervisor and document that they have done so in their intra-bout notes section on Annex C page C-2.

Referral of an injured boxer to hospital

36. Boxers should go to A+E or the neurosurgical centre by ambulance [18], on oxygen with airways supported, in the following circumstances:

a. Boxers to be transferred immediately to neurosurgical centre with doctor escort. Any boxer who suffers a Loss of Consciousness (LOC) [19] and who fails to recover consciousness inside one minute or any other boxer whose clinical condition is such that the doctor deems it necessary. Urgent liaison with air ambulance transfer capability in such circumstances will normally be considered appropriate by evacuating paramedic staff. This requirement is rare. If it arises the following must occur:

(1) The tournament will be suspended unless a replacement suitable doctor is present and a second alternative ringside ambulance is obtained and prepositioned.

(2) Supervisor must notify the sS Boxing Association Secretary and SMO CSBA10, preferably at once by voice or text or at the latest on the next working day.

b. Boxers to be transferred to A+E without doctor escort. Any boxer suffering a Knock Out (KO)19, a Technical Knock Out (TKO)19 or otherwise who shows signs of concussion at a post-bout check which fail to rapidly improve with oxygen, but whose clinical condition is not such as to demand immediate transfer. In accordance with National Institute for Health and Care Excellence (NICE) guidelines on head injury management [20] any boxer who is KO’d and rendered unconscious must be transferred to hospital with a view to CT scanning, even if they appear to have recovered fully, as such precautionary scans are mandated clearly within this guidance for all LOC with this sort of injury mechanism.

37. This is not an exhaustive list, for example cases of possible fractures or shoulder dislocations will also need to be taken to A+E etc.

Post-bout medical examinations

38. All boxers must have a post-bout medical examination. The post-bout examination of any boxer losing by a KO or TKO must be carried out by the Ringside Physician. The Ringside Physician may apply clinical judgement and delegate the task of carrying out other post-bout medical checks to their assisting paramedic(s)[21].

39. The Ringside Physician must record their personal findings on page C-2 of Annex C. The paramedic’s post-bout checks are to be recorded on the Record of Post-Bout Checks for Medics, Annex D.

40. Certain injuries require periods of suspension from sparring and boxing and normally from routine organised Physical Training (PT) [22]. The standard suspension periods designated in the international rules are summarised at Annex E for quick easy reference and all doctors undertaking ringside duties must familiarise themselves fully with these.

41. Suspension periods (and what the injury was) must be recorded by the Ringside Physician legibly into the BCR1 on the right hand side in red ink using the following wording – ‘Unfit to box, spar or train for XX days AND until post suspension renewal annual medical re-examination has been passed’.

42. The suspended boxer’s BCR1 is retained by the Supervisor, for next day forwarding to sS Secretary, only to be released back to the boxer/coach at the end of the suspension, to take their record book when attending for a renewal annual medical.

43. The boxer must be issued with a Head Injury Advice Sheet (Annex F) when clinically appropriate, and when a suspension has been applied, with a Notice of Boxing Injury (Annex G) to take to his unit doctor on the next working day to ensure the injury is documented into their eIHR.

Injury follow up

44. Any boxer, who is injured, suspended or who loses by KO, TKO or Technical Knock-Out with Injury (TKOI)19 must report sick the following working day morning. This ensures review by their own doctor, certification of light duties or temporary downgrading if required, and scanning of the Notice of Boxing Injury (Annex G) onto eIHR.

45. The doctor is to document the history, any suspension awarded and current examination status of the boxer on the eIHR using the Boxing Injury template accessed within the Boxing Medicals Protocol. If any uncertainty arises as to the boxer’s Central Nervous System condition, a very low threshold for referral for immediate CT scanning is to be applied.

46. Unit boxing officers and coaches are to ensure that boxers on post-bout medical supervisions do not box, spar or train until cleared to do so by passing a post-suspension renewal annual medical with their unit doctor.

Documentation management from medical cover

47. All paperwork completed as part of boxing medical duties must be scanned into eIHR and then shredded as per the direction given in JSP950 Part 1 Lft 1-2-11 Defence Healthcare Record.

Medical Officer’s Ringside Dress code

48. This is a matter for individual Medical Officer’s (MO’s) discretion. There is sometimes pressure from units for the MO to wear mess kit as per the officers who are spectating. However, as the MO is on medical duty it is important that they wear suitable uniform for carrying out their role and mess kit is normally considered unsuitable for getting quickly into the ring etc.

Data recording on Injury and Non-Injury Rates

49. The Record of Boxing Injuries and Non-Injuries in a given Contest at Annex H is to be completed after each bout by the doctor in conjunction with the Supervisor. Once completed it is to be sent by email (ensuring that patient confidentiality is protected) to their sS Boxing Association’s SMO/Medical Advisor as well as to SMO CSBA10 for addition of the data to the sS’s and CSBA’s databases for recording boxing injury and non-injury rates. There is a steadily accumulating evidence base about service boxing rates of injury and non-injury, based on data collected on over 4200 boxers over 5+ years [23].

Medico-legal Indemnification

50. MOD indemnity covers directly employed (uniformed and CMP) doctors who provide ringside medical cover to Service sponsored sporting activity including boxing. This applies whether the boxing is taking place on or off a military base and whether the boxers are all military or mixed military and civilian. The medical personnel must ensure that they are practicing within their scope of practice and be current. Further details on indemnity can be found in JSP 950 Part 1 Lft 10-1-7 Indemnity for Medical Personnel. Non-directly employed medical staff supporting service boxing events must provide their own indemnification having reassured themselves in writing (eg by email) that their indemnification body knows they will be pursuing ringside duties and will cover these.

51. If choosing to assist in civilian events MOD-employed doctors must provide their own indemnification for such work as MOD indemnification will not cover them for such extra-curricular activities. Ensuring the adequacy of such indemnification is a matter for individual professional due diligence; as a minimum this must include obtaining confirmation of indemnification in writing.

Registration with England Boxing

52. Doctors who already do, or in the future intend to do, Ringside Physician duties must register with England Boxing (EB) by emailing enquries@englandboxing.com. The register is designed to allow EB to develop a database of doctors engaged in this work, to facilitate planning of future EB sport-specific doctor’s training etc. The minimum dataset required is name, GMC number and a contact email address; that can be an MOD work one or a personal one as preferred. Provision of a mobile contact number and any geographical location information is optional. For civilian clubs, the register is also to allow EB to easily advise event organisers of available boxing-registered doctors in their area. When service doctors register with EB, they should either specify ‘service-boxing-only’ to be placed on the services boxing only part of the database or if they are willing to assist civilian clubs in their area, they should register as ‘service+local-civilian-boxing’, indicate in which area of the country they are based and attend to indemnification issues as at Paragraph 51.

Safety in Sparring Training

53. Injuries arising from sparring as opposed to boxing per se remain a concern as sparring does not attract the full ringside medical cover arrangements mandated for an actual boxing event. Therefore, regulating this area is vital and requires attention to standards of equipment, risk assessments, coaches’ training and qualifications. Annex C contains further details. CSBA will publish separate direction on this area to disseminate to all service coaches etc.

Milling

54. Milling is an Army-only activity, mentioned here for completeness for Army readers only, which consists of brief spells of boxing-like activity undergone in the course of P Company selection and related activities. Standards of medical cover required in terms of medicals and medical cover are identical to boxing as set out above, the only difference being that for milling, headguards are still to be worn. For further information, contact OC P Company [24].

Annexes:

A. Guidance Notes for Doctors Performing Boxing Medical Examinations.

B. Statement of Annual Boxing Medical Examination and Informed Consent to Participation in Service Boxing.

C. Pre-bout Medical Examination.

D. Record of Post-bout Checks for Medics.

E. Ringside Injuries Suspension Periods Required.

F. Advice Card for Boxer’s Suffering Head Injury.

G. Notice of Boxing Injury to an Individual Boxer.

H. Record of Boxing Injuries and Non-injuries in a Given Contest.

[1] In boxing, as in karate, kick-boxing, taekwondo and other combat sports, points are scored for landing blows with force on the opponent. Similarly, injury risks profiles can be defined for non-combat sports such as rugby, skiing, riding, parachuting, etc.

[2] http://aiba.s3.amazonaws.com/2015/02/AIBA-Technical-Rules-01.02.2015.pd Accessed 2 Jun 15.

[3] http://www.boxing.ca/documents/2-medical%20handbook%202013.pdf. Accessed 2 Jun 15.

[4] Doctors may refuse (on professional or ethical grounds) to undertake boxing medicals. If choosing to do this, they must seek to make alternative arrangements for a colleague to undertake these medicals, as a doctor would do re care of a woman seeking a termination with which request they decline to assist for professional or ethical reasons.

[5] Most annual medicals are valid for a full 365 days from the date of the medical; a few exceptional cases like international boxers will expire at 31 Dec of the year in which they are done (unless ended earlier by suspension).

[6] These results are now easily coded into eIHR using the outcomes to the annual medical in the new boxing medicals protocol.

[7] Red or partially red coloured mouthguards are not allowed for boxing; instead, a light colour should be used, preferably clear or white. Defence Primary Healthcare Care (DPHC) Dental Centres can supply mouthguards for service boxing subject to other clinical priorities and adequate knowledge for their construction. Guidance on custom mouthguards can be found at: http://defenceintranet.diif.r.mil.uk/libraries/library1/DINSJSPS/20110714.1/20121011-8-AVB-JSP_950_2-23-1_SG_PSD_PDC_Part_2_Attachment_I_May12.pdf Annex I. Accessed 3 Jun 15.

[8] Doctors who already do, or in the future intend to do, Ringside Physician duties must register with England Boxing (EB) and details of how to do this are detailed later in this policy at Paragraph 52.

[9] Ie GDMOs who attend at the ringside would do so in an entirely supernumerary basis for training and experience purposes only.

[10] SG-DMed-SMO CS ArmyBoxing@mod.uk with cc copy to smocsba@gmail.com

[11] If the boxing that the CMP volunteers to cover occurs out of normal working hours (eg an evening event), negotiation of return of time back in lieu when mutually convenient is normally considered standard practice.

[12] For example, an ambulance designated to an operational airfield’s medical cover cannot be additionally allocated to boxing without the airfield being closed.

[13] Military ambulances which are unlicensed for use on the public highway are not to be used for transfer of an injured boxer to hospital in contravention of their unlicensed status. The frequently applicable implied requirement for buying in cover from a civilian ambulance with paramedic crew and equipment is recognised: sS boxing associations make their own arrangements about budgets to cover this.

[14] Head Medical Strategy and Policy, HQ Surgeon General, on advice from the local Service medical authority.

[15] The Supervisor sits ringside two seats along from the Ringside Physician and so is easily accessible to the Ringside Physician for any liaison that may be needed.

[16] See AIBA Technical Rules page 16 Rule 13 for specific definition of term.

[17] If the Ringside Physician does not agree with the medical team member and they remain concerned they should raise it directly to the Supervisor as the safety of the boxer is paramount.

[18] Either the pre-positioned Ringside ambulance or a 999 summoned one, A+E or neurosurgical department to be notified whilst the boxer is on route.

[19] Definitions of these terms are in the AIBA Regulations 2 and the AIBA Medical Handbook 20133.

[20] https://www.nice.org.uk/guidance/cg176. Accessed 2 Jun 15.

[21] Delegating in this way aids the flow of the competition with the doctor only called from ringside to make post-bout checks if concerns arise from their assistant’s checks.

[22] If the suspension is over 30 days, this clearly may imply temporary downgrading action for the duration of the suspension period. Suspensions for a period to allow time for a laceration to heal should restrict participation in sparring and boxing but allow normal PT whereas suspensions for most other injuries should also restrict participation in normal PT for that period. Omit ‘or train’ from the BCR1 suspension statement where the injury concerned is a laceration.