Well isn’t THIS special? After years of not posting (largely because I haven’t really felt I’ve had anything to say that would interest anyone) here we go again!
Tiny bit of background: for the past three years I’ve done quite a bit of doctoring at various combat sports events, sitting ringside helping to take care of the fighters (including all UFC events in Abu Dhabi since July 2020). Make no mistake about it – I am not a fan of combat sports, but for various reasons, and the odd meanders of a career, this is a position in which i often find myself (it is a very compelling gig, and one I take extremely seriously).
Last night, during UFC 294 and on the ref’s request, I assessed Johnny Walker after he was struck on the head. I recommended that he stop the fight, which of course he did.
My assessment would appear to have provoked a mini-maelstrom of opinion and comment, and I think it only fair to explain the process by which I reached my conclusion in the octagon, and to make clear that in many respects this was the only possible, only safe, and only reasonable decision based on current understanding of head injuries. I want to help clarify the sometimes agonizing position the ringside doctor is in, and the way one of them (ME) reasons when faced with this type of decision.
First, let’s paint a picture of the situation. Johnny gets a blow to the head, is clearly staggered, and I stand up from my ringside chair, knowing that Dan (the ref) would call me in to assess the fighter. I had not seen the blow (my angle was not ideal) but saw Johnny’s reaction, and as I entered the octagon I saw the expression on Johnny’s face. You need to remember I’ve spent 25 years as an ER doc and anesthesiologist, and 16 years in Formula 1, and three years ringside – plenty of time to have assessed hundreds of patients with concussion – and enough time to know that look.
I approached Johnny, and asked him some standard questions. Often the precise answer is not important – it’s more HOW the subject arrives at the answer. Long story short, Johnny was disoriented in time and in space. Telling me he was in the desert was pretty good, but not good enough. And the notion that a language barrier prevented him from answering me correctly is either adorably naieve, or willfully disingenuous. Johnny KNEW what i was asking, but just could not answer it.
Why is this important? Well guys, the definition of a concussion is, roughly, “altered brain function after a blow to the head”. This can take several forms, transient amnesia (like forgetting where you are and having to improvise an answer) being one of the most frequent. Oh and Johnny did not remember for the life of him what round it was. Pretty sure most (non-concussed) fighters always know exactly what round they’re in.
Once we’ve accepted that we’re now dealing with a concussed athlete, the rest falls into place clearly, if painfully. Now of course if the diagnosis involved the persistence of symptoms (so we’d have “altered brain function one minute, five minutes, one hour, etc, after a blow to the head”) I’d have had to take that into account. But the definition of concussion does not depend on how long after the blow to the head we are. The SEVERITY of concussion will be partly judged by the persistence of symptoms, but that’s not the question here
Current consensus, in essentially every sport that has a concussion protocol – and I mean EVERY SPORT – is to immediately remove that athlete from further competition until carefully assessed. I’ll not be pedantic but I do need to emphasize: EVERY. CONCUSSED. ATHLETE. REMOVED. IMMEDIATELY.
Note that I said “until carefully assessed”. There are several ways to “carefully assess” a concussed patient, from computer-based neurocognitive testing to vestibular (balance) -based examinations , to detainled neurological exams- but all of them require time and expertise to carry out. And remember that current best-practice is that this athlete cannot return to this event, and perhaps even upcoming events, until this is done AND ALL SYMPTOMS OF CONCUSSION HAVE RECOVERED. That’s right – the athlete needs to have recovered completely before being allowed to return to competition. If you look at the concussion management protocols in sports, you will pretty much always see that the concussed athlete will almost never be allowed to return to the game/match/event in which he or she was injured.
You see where I’m going with this, right?
Several of the officials and staff spoke to me after the decision, and while obviously not getting involved in the medical aspects of the decision, they often suggested that perhaps I should have given Johnny “some more time”. Let me throw this back – how much time? And after that time has elapsed, what am I looking for? So let’s say we decide five minutes. Great. We’re now five minutes later, and I ask Johnny what day it is. “October 21, a Saturday”. “We are at the end of the first round”. “This is Etihad Arena in glorious Abu Dhabi”. Well after you pick me up off the floor (there was no way on God’s green earth THAT was going to happen, remember I know a concussion when I see one), but even had this happened – was this enough to constitute a “complete and thorough assessment”?
The answer of course is no, not by a long stretch – but now consider the ringside doctor’s dilemma. Those three correct and elegantly phrased answers are pretty good evidence of marvelously rapid recovery. But if I’m officiating at an amateur bout, or a college football game (and these answers are given on the sidelines) I’m keeping this guy out until we do some REAL assessment. On the other hand, had those answers been offered last night by Usman, or by Alex, or by Johnny himself had the same situation occurred, I’d likely have let the fight continue. Not that I’m any less concerned (although massively reassured), but because I realize the context. The ringside doctor in high-level combat sports confronts this constantly. But always, ALWAYS, our duty to the guy in front of us outweighs anything and everything else.
And remember, this is not what happened. In fact, Johnny got a bit uncontrollable, something that fans love, but that is very rare, and that likely reflects a serious temporary deficit in impulse control. Something that, you guessed it!, is part of the concussive syndrome itself.
Just to reinforce what I’m saying, Johnny was foggy enough at his post-fight exam that he was required to be observed for some time to make sure that his recovery was well underway before clearing him back to the hotel.
You know, if Dan had called me into the ring for a cut, a bad one, to assess whether or not we could continue, my criteria for stopping the fight would have been different here, with these guys, on the main card, for this event, than if this was a college boxing match. I GET THAT. This is, after all, a form of showbiz, and stopping a fight is heavy with consequences. Again, I GET THAT. Criteria for a lot of stoppages are . . . adjustable . . . given that we’re dealing with mature consenting adults who take risks as part of their jobs. I GET THAT.
BUT NOT WITH HEAD INJURIES. Sorry, but here the criteria are absolute. I don’t care if this had been Muhammad Ali, for a world championship fight, I’d have made the same recommendation. Or your kid. You’re concussed? You’re finished for tonight. Period. Move on. That’s my job. You don’t like it? Sorry. That’s my job. You bet on the fight and lost? Sorry. None of these are my concern, none of these are my problem. My problem is Johnny Walker, his brain, his future, his wellbeing.
So there you go folks, this is pretty simple. I had a concussed fighter in front of me. One whose recovery could not be properly assessed in the timeframe necessary to allow THIS fight to continue. I owed this to Johnny. If it were your son or daughter, in another sport, any sport, I’d do the same thing. If this happened tonight, despite the opprobrium being heaped on me, I’d do the same thing. Getting a second concussion before the first has healed (and do not doubt for a moment that given his cognitive slowing Johnny was well on his way to being TKO’d – at best – or KO’d – at worst) can lead to the “second impact syndrome” where the athlete collapses, and usually dies, from massive acute brain swelling. That’s not going to happen on my watch, I promise.
Finally I want to thank Dana White for having said that my inexperience was responsible for my decision. It’s better than attacking me, for sure. I have acquaintances who have thousands of fights under their belts; I’m somewhere north of 500. But Sid Watkins and I started concussion testing – pre-season baselines and post concussion – with a computer based program, in the late 90s. THIS WAS DECADES BEFORE ANY MAJOR SPORT (except IndyCar) GAVE A DAMN ABOUT CONCUSSION. And again, my career involved caring for hundreds of “day to day” concussions. So actually not only am I not inexperienced, but in a certain way Johnny was damned lucky I was his doctor last night.
I want this to be read by a max of fight people who question the decision. Help me out in the comments as to the tags I use to make sure that they land here.
I welcome your comments – but keep it respectful, keep it fact-based, be normal. If not I’ll just can it. I won’t have massive amounts of time for a give and take, but those of you who’ve read me in the past know my commitment to furthering knowledge of head injuries of all types.
Well that was fun, it’s nice to be back!
A Former F1 Doc Writes 