Corners' corner

[Garland]

Alright...I, as a combat athlete who's been out of the ring for awhile due to local...of all things, liquor laws...and hence haven't kept my conditioning up...want to learn other aspects of the sport, and hence gain a better knowledge of the games and sports themselves want to learn more about being a good corner and cutman.

I hope that others will contribute to this thread with advice for becoming a good corner, and some more detailed instructions and hints as to becoming a good cutman, especially the medical and technical aspects of such. (perhaps also the psychology of becoming a better corner, such as trigger commands and keeping a fighter relaxed and at the top of their game during a fight)

[Garland]

CUTS: Part I: CUTS...TO STOP OR NOT?
by Margaret Goodman, MD

As a boxing fan, how many times do you sit there and wonder WHY a doctor let a bout continue, and other times WHY they stopped the contest? As a ring doctor I, myself, wonder a great deal of the time. So, I know boxers, cornermen, and TV commentators must face the same quandaries. What is the answer..or is there a right answer? Unfortunately, if things were this simple there would never be any controversies. Things would be a great deal less interesting, but there would be consistency. No fight is the same, no two fighters are the same, no doctor is the same, and each cut is different. However, there are some rules we can follow.

Cuts are rarely stopped on their own merit. A cut should stop a fight if it is 1) giving the opponent an unfair advantage; 2) allowing the fight to continue could cause irreparable damage to the boxer; or 3) the boxer is losing nearly every round AND taking blows to the head. Deep cuts are dangerous in the sense that they can necessitate the use of a plastic surgeon, an operating room repair, intravenous antibiotics/hospitalization, and a drain hanging out of the laceration for a few days. You want a fighter to not have to take too much time off after a fight, especially if he is just beginning his career.

The most common place for a fighter to get cut is around the eye; usually just below the bony brow. If it is on the eyebrow, it is usually not an issue. If lower, you have to evaluate the depth. If a cut of this nature becomes too deep it could affect the eye muscles that move the eye and result in double vision, or if too severe could lead to ptosis(drooping eyelid). Furthermore, if this type of laceration is close to the inside corner of the eye, it could injure the tear duct (causing a dry eye and frequent infections). If a cut below the brow is in the crease of the eye, or more importantly on the part of the lid that covers the eyeball, these are dangerous, and there is no discussion. Below the eye (lower lid) close to the eyelashes is very difficult to repair. If allowed to continue, the boxer might require surgery. Even then scarring could produce an eye that doesn't close properly (like a Basset Hound). When checking a cut around the eye, the doctor is also making certain the fighter can see. A laceration from a punch or butt can sometimes injure the eyeball itself or occur along with a fracture of the orbit (eye socket). This is certainly a reason why a cut may not look deep, yet the ring doctor has to stop the fight.

Cuts on the forehead or scalp are usually the result of a head butt. Although these are often deep, they rarely require a stop. Exceptions are if blood is obstructing the boxer's vision or there is way too much blood loss. Cuts right above the brow (if deep) can affect the ability to lift the eyebrow. These need to be watched closely as they could result in permanent disfigurement.

Blood from the ear is pretty uncommon in a fight. It can have serious consequences. It can represent a busted eardrum and perhaps even a basilar skull fracture (a fracture at the base of the skull). The doctor needs to try to assess where the blood is coming from. If this can't be done easily between rounds, the fight should stop.

Lacerations to the cheek (deep or superficial) are usually little to worry about. Arturo Gatti had a nasty cheek gash while fighting Oscar de la Joya. It looked bad, didn't affect his performance, and was easily sutured after the fight.

Nasal problems will be handled in a different article. However, sometimes a fighter is cut across the nose. Typically this is no problem, unless the fighter ALSO appears to have a broken nose. The two together means an Open Nasal Fracture until proven otherwise. This requires surgery and a few months off.

Lastly, bleeding around the mouth can often be from the nose. Not a problem unless it causes nausea. More than a few of us saw poor Robbie Peden vomit on "HBO After Dark" from swallowing too much blood. However, if the fighter has a cut on the tongue (received from an open mouth, badly fitting mouthpiece, and a punch), or on the inside lip, these can bleed profusely and the bout must stop. If the laceration involves the Vermillion border (the line between the lip and face), these are very difficult to correct with stitches. The fight should stop as letting it go could produce scarring which might prevent the mouth from closing properly.

So, now we have it all figured out!

Sorry, no such luck.

Of course, some cuts eliminate any discussion. In truth, many other factors enter into the absolute decision. If the cut occurs in the last few rounds of a ten-rounder or championship bout, as long as the fighter isn't taking too much punishment, you allow him to continue. On the other hand, if the fighter is just beginning his career, he is in a four rounder and has a big gash, you would be inclined to get that guy out of there. You want the fighter to not have to take too much time off from the gym and resume their career. Allowing a cut to get too deep necessitates weeks, if not months, off. This isn't good for a young boxer just starting out. Experience counts a great deal. It is fascinating to watch a fighter who has never been cut before. Some boxers simply fall apart the first time they get cut. They forget they ever had a game plan and have problems continuing. Older, more experienced fighters are often indifferent to being cut in a fight. They handle it well and the doctor can relax.

What makes a cut bleed? Some areas on the face are more vascular than others. A cut doesn't have to bleed to be serious. The contrary is also true. Some fighters bleed more when they have been using anti-inflamatories like Aspirin, Advil, or Motrin. Tylenol is the only anti-inflammatory that doesn't lengthen the bleeding time, and is therefore safe for a boxer with an upcoming fight. Lastly, fighters that bleed a lot have often been cut before in the same place. The first laceration wasn't allowed to heal long enough, so they bleed again.

A good cutman can be the best investment for an up and coming boxer. Their job is crucial to a fighter's success in the ring. How to handle facial swelling, and stop a cut or the nose from bleeding will be handled in an upcoming article.

In the end, just like the rest of medicine.and boxing, THERE ARE EXCEPTIONS TO EVERYTHING! Hopefully, this will let you in on just some of the things the ring doctor thinks about when examining a cut during a fight.

****Boxing is a blood sport. No fighter should enter the ring before testing negative for Hepatitis B/C and HIV. Note: immunization can be given for Hepatitis. Consult your local athletic commission if questions.

[Garland]

By Flip Homansky MD

The cut man has now been elevated to the level of rock star. He brings magic potions and salves and his deeds are valued by all at ringside. The wondrous weapons of his trade (the Q tip and enswell) are in evidence for all to see. He even usually dresses in a way that distinguishes his art. What in the hell is he actually doing to the cut? What does work to stop bleeding, and what is legal? How important is a good cut man, and must he inflict pain to be effective? I am going to try to answer these and other pressing questions that you didn't even know you asked.

A good cut man is invaluable to every fighter. He can truly be the difference between winning and losing. I have seen countless fights that were stopped because no one in the corner knew how to prevent a simple cut from getting worse. This is most obvious in many undercard fights, women's bouts, and mixed martial arts contests. If I was a young fighter, I wouldn't skimp on three things; my mouthpiece, my cup, and my cut man.

How should a competent cut man be chosen? Look for experience, someone who is calm, and talk to other fighters about who is good. There are a number of physicians who do an excellent job in the ring, but an MD degree is no guarantee that the holder knows a damn thing about jagged lacerations that are acutely bleeding. The ring is the most unlikely operating room that I can imagine. I would also worry about the guy who has so many Q tips in his mouth that he may choke at any time. Another concern of mine is the cut man with so much Vaseline on his body that he will slip getting into the ring and slide across to the other side. This would indeed be poor form!

This is not a new art. There have always been people in the corner who understood bleeding, and how to stop it. Yes Martha, there was a cold flat piece of ice before there was an enswell. Fights in the old days were longer, and frequently more brutal. When lacerations occurred, they were stopped by pressure (preferably cold pressure), and adrenaline. The current armamentarium is more extensive...but the cut man shouldn't forget the basics.

A) Minimize the use of drugs that make bleeding more likely.

Aspirin (effects on platelets are profound and long lasting) as per Dr. Goodman.

Advil, motrin and aleve are all essentially the same.

Steroids will make skin thinner and definitely increase chance for bleeding.

B) Know your fighter.

You should be aware of prior lacerations and how the fighter reacted to his own blood. Any old laceration should be checked, and a fighter should not be hurried back into the ring until there has been relatively complete healing (more on suspensions in a future article).

If he or she has sustained any swelling or abrasions during training - address those before the actual fight begins.

C) Watch the fight closely for any signs of trouble that could be a prelude to a cut.

You don't have to wait to see blood before you begin to treat an area of concern.

D) Understand the anatomy of the face, including the difference between arteries and veins.

Will be addressed in more detail in the future.

E) Pressure.

This is the key to stopping all bleeding.

Time is important here, and you must begin treatment immediately after the fighter reaches his corner. Don't get in the way of the trainer...but be ready to do what must be done. The trainer can give instructions from the side, but you have to be in position to see the face completely. Firm, continuous pressure will begin the process of stopping the bleeding.

F) Cold.

Cold is a natural vasoconstrictor; that is, it will make blood vessels constrict or narrow. This process will decrease the amount of blood going into the field of the cut.

The ENSWELL is nothing more than a flat or molded piece of metal that can be kept in ice and used to apply firm direct cold pressure to a laceration.

One of my biggest concerns about cut men is when they use the enswell as a weapon! There have been times when I have seen more damage inflicted by this simple tool than by the opponents' fists. Firm direct pressure does not mean trying to push the swelling away from the affected area. If there is swelling around an eye, you cannot make it disappear by using extreme force to try and rub it away from the eye. Remember, the swelling comes from cell fluid leaking into the damaged tissue. If you force it away by hard rubbing, you are simply damaging more tissue - and will ultimately cause more swelling. This could work for a round or two, but ultimately the swelling will increase if you use the enswell as nothing more than a rolling pin. Think about it!

G) Vaseline.

Obviously makes the skin slippery and less likely to tear. Other agents can be incorporated into the Vaseline. Never use gobs of Vaseline...will just end up on gloves and hence in eyes.

H) Adrenaline (epinephrine).

Used in a concentration of 1:1000. Safe when used topically. Natural chemical that will be absorbed in the open skin and decrease blood flow. (Newer Agents)

I) Avitene.

Microfibullar Collagen Hemostat. In contact with bleeding surface, will cause platelets to adhere and form quick clot.

J) Thrombin.

Protein that forms clot with fibrinogen.

K) Surgicel, Gelfoam, etc.

L) Monsels solution.

This is a lead based homeostatic that will work by destroying the surrounding tissues. It is or should be illegal in all locales. Can be spotted by the black ring of dead flesh around the cut.

I have seen these agents used interchangeably by cut men. They have heard of these cool drugs, and want to use them. They are NOT interchangeable! For example, Avitene can only be used if cut is actively bleeding, and Thrombin can only be used if blood is removed first and surface is dry!

One last pet peeve... a Q tip has a soft cotton end and should always be used gently. It is useful to help apply medicine to a specific area. The key word is "gently". Why wield it as an instrument of terror in the corner. I have seen a large Q tip stuck forcefully up a bleeding nose. Think about this! The inside of your nose is super sensitive, and quite delicate. The correct way is to gently apply the medicine just inside the nostril and then apply pressure over the outside of the nose. 98% of all nasal bleeding is not deep within the nose, but actually very near the opening. Most of the significant blood vessels that bleed in the nose are not located deep within that poor orifice that has already been taking a lot of punishment from the opponents fists. Stop Sticking that Q tip in so Deep!

In closing...the cut man is an invaluable member of the team at ringside. The majority attempt to do all they can to help their fighters. I continue to learn from them. My basic tenet is to " do no harm ".

Flip Homansky MD.

One of things I try to do is always perfect my trade. It is crucial to know your fighter and learn everything you can to do the best job possible for them. I have worked on some nasty cuts in my day and I have seen some horrible bruises. Facial swelling (trauma) around the eyes is something I would like to touch on. Why is it that so many cutman take an Enswell and vigorously rub the swelling from one side to the other? Did you ever wonder why? I did that, and that is why I am here to say that not only is it more damaging to the eye, but completely UNNECESSARY! If you think you're trying to move blood away from the eye. WRONG! think again. We cannot possible move blood in that way and expect it to stay. It moves on its own and will take the path of least resistance. I have confirmed this with Dr. Margaret Goodman and Dr. Flip Homansky of the Nevada State Athletic Commission.

Gentlemen and ladies, the easiest and best way to reduce swelling during and after a fight is simply taking one hand and apply firm pressure with the Enswell or an ice bag on top of the area of trauma. Place your other hand behind the fighter's head. In this way, and this way only, the swelling starts to subside. Hold the Enswell as long as you can. A minute between rounds isn't long, but it often enough time to make a difference.

NOSEBLEEDS. Here again, it is pretty simple. The key is PRESSURE. Using your Q-tip soaked in Adrenalin hydrochloride, place it gently inside the nostril. There is no need to jam it up the nose, as it will cause more harm than good by further traumatizing the area. With your other hand, hold the nostril up against the Q-tip. If it is a normal nosebleed, this should take care of it. Also, a cold icepack can help. I generally like to use those freezer bags filled with ice, as they stay very cold.

If you have a continuous heavy flow of blood coming from the nose that is dark in color, chances are the nose is broken in some way and you will have to work fast with your coagulant, pressure, and ice. Now guys, remember the ear, nose and throat are connected to one another. Make certain you tell your fighter to breathe through his mouth when you apply the coagulant. You might also want to look inside his mouth to insure he is not swallowing too much blood that could induce nausea or vomiting.

Lastly, never hesitate to check with the ringside physician during the fight about a nosebleed. I do it, AND it won't make you any less of a cutman.