Recent deaths of Japanese boxers underline importance of emergency action plans

Japan Times

12 hours ago

Boxing, a sport many see as too dangerous, is once again grappling with questions of safety and protocol after two Japanese boxers in their 20s died within a day of each other from fatal brain injuries suffered during separate fights on the same night.
Shigetoshi Kotari died on Aug. 8 and Hiromasa Urakawa on Aug. 9 after competing in different fights on the same card at Tokyo's iconic Korakuen Hall on Aug. 2. Both boxers underwent surgery for subdural hematomas — a condition in which blood collects between the skull and the brain.
Kotari lost consciousness in his dressing room after going 12 rounds against Yamato Hata in a bout for the Oriental and Pacific Boxing Federation (OPBF) super featherweight title that ended in a draw. Urakawa, a lightweight who appeared on the undercard in an 8-rounder against Yoji Saito, collapsed in the ring after a technical knockout loss in the final round.
Four Japanese pro boxers, including Kotari and Urakawa, have undergone craniotomies in the past two years, with three of the cases resulting in death. In February 2024, Kazuki Anaguchi died after sustaining a brain injury in a December fight. The only survivor, former International Boxing Federation minimumweight champion Ginjiro Shigeoka, remains in a coma following his May 24 bout with Pedro Taduran.
Serious injuries and deaths in the ring are called ringuka (literally, ring crisis) in Japanese.
Since the Japan Boxing Commission (JBC) was established in 1952, about 40 boxers have died as a direct result of injuries sustained in the ring, according to the Asahi Shimbun. Though boxing fatalities are statistically rare, they highlight the inherent risks of the sport.
Shunji Asamoto, a neurosurgeon and a doctor with the JBC since 2018, says that most boxing deaths occur after a single powerful punch to the head or a series of punches in quick succession, rather than repeated blows over a long period of time, which is linked to impaired brain function or chronic neurological issues.
'Acute subdural hematoma is the most common cause of boxing fatalities and unfortunately, there is no way for a boxer to have zero risk of acute subdural hematoma,' Asamoto said.
'Due to the nature of the sport, blows to the head are unavoidable, and these can potentially cause acute subdural hematoma. While CT scans and MRIs are useful for assessing brain health, they don't reliably predict the possibility of an acute subdural hematoma developing in the future.'
Kotari and Urakawa's deaths made headlines around the world, with major media outlets such as CNN and BBC reporting on Japanese boxing's double tragedy. The World Boxing Organization was among those who paid tribute to the late boxers on social media.
Brian Sutterer, a U.S.-based physiatrist and YouTuber with 826,000 subscribers, provided his perspective on how to prevent similar incidents from happening in the future in a video released on Monday.
In the video, Sutterer reads the English translation of an X post by Kotari's older brother. The brother questioned the venue's emergency protocol, which he said instructs the on-site doctor to first notify a venue staff member, who then contacts 119. He also expressed anger over what he said was a long wait for an ambulance (which he claimed was a little over 40 minutes) and that his brother had to be carried down five flights of stairs because the stretcher wouldn't fit in the elevator.
'So it sounds, at least from reading his brother's presentation of what happened here, that the way to look for improvements in this unfortunate case is that emergency action plan,' Sutterer said. 'It's 'what can we do to improve how quickly emergency personnel can get to the venue?''
JBC Secretary-General Tsuyoshi Yasukochi told reporters on Sunday he believes there were no errors in the way the medical emergency was handled.
'However, we must investigate whether we truly did everything possible,' he added. 'Additionally, we are researching the medical response measures implemented by commissions in places like Nevada and New York. If there are elements that can be introduced in Japan, we would like to adopt them proactively.'
In response, the JBC announced all future OPBF and WBO Asia Pacific title fights in Japan will be reduced from 12 to 10 rounds.
Some boxers take various measures to shed excess grams — especially right before weigh-ins — in order to make weight ahead of fights. This rapid weight loss can lead to dehydration, which the World Boxing Association says makes the brain more susceptible to bleeding.
Japanese boxing officials said they would introduce urine tests to measure hydration, enforce stricter rules on weight loss to prevent dehydration and improve medical coverage at bouts following the deaths of the two fighters last week.
Under the new rules, ambulances will also be required on site, even for non-world championship bouts — already a requirement of the Association of Boxing Commissions and Combative Sports, which governs U.S. boxing commissions. They will partner with hospitals that are equipped to perform emergency surgery for head and other injuries.
Asamoto, who has served as a ringside physician 'too many times to count,' thinks simply having an ambulance on standby isn't enough. He, like Sutterer, says an emergency action plan (EAP) must be priority No. 1 in boxing.
'An EAP is a preestablished sequence of actions, covering everything from initial ringside response when a fighter is in critical condition, to transportation by ambulance and the start of specialized treatment at the receiving hospital,' he said.
'Without this plan, crucial decisions — such as which hospital to contact, how to contact them and who will accompany the patient — can be delayed in an emergency. In cases of acute subdural hematoma, emergency surgery is highly likely to be required. To increase a fighter's chances of survival, it's critical to minimize wasted time at every stage.'
But Asamoto admits that, generally speaking, the primary challenge in an emergency in Japan is not getting an ambulance to the scene, but finding a hospital that can accept the patient. This is due to factors such as hospital capacity, bed availability and specialized treatment needs, which can lead to delays in providing necessary care.
'Hospitals treat a wide variety of patients,' he said. 'Therefore, it is practically impossible for a hospital to refuse other emergency cases or to reserve an operating room solely for a boxing match — that is, to have an anesthesiologist, neurosurgeon and nursing staff on standby.'
'Finally, acute subdural hematoma is an extremely dangerous condition that is often difficult to treat successfully even with rapid intervention, and it carries a high risk of severe long-term complications. Among head injuries, acute subdural hematoma is considered one of the most serious and troublesome conditions.'