(This story first appeared in the Louisville Courier-Journal.)

The referee’s signal sent Donshay White scurrying from his corner to the center of the cage.

Just the second round, White was glistening with sweat as he exchanged punches with his heavyweight opponent.

Within minutes, measured uppercuts and jabs gave way to aimless, windmill-style flailing.

Cheers erupted from a rowdy crowd of 800, fueled by $3 beers and a taste for amateur mixed martial arts. The roar echoed through the Expo Five Concert and Event Venue, a converted warehouse a mile from Churchill Downs in Louisville.

Without warning, White slowed. His knees wobbled. He stopped swinging.

He gasped for air.

The crowd’s noise drowned out the thud of his 210-pound body crashing to the black mat.

Opponent Ricky Muse crouched above him, landing punches – one after another – to White’s head.

White’s girlfriend, Denise Cason, watched in horror. He was her best friend and the father of their 2-year-old daughter, Raven, and he was visibly struggling.

She knew he had not trained for this fight, his first in nearly two years.

The referee ended the fight at the 5-minute, 22-second mark. Spectators cheered the victorious Muse. Then, they grew quiet as they realized something was wrong with White.

The 37-year-old factory worker lay still. His arms were behind his head and his chest heaving as he sucked in air.

Two men lifted his limp body, supporting him under his arms. Backstage, White collapsed again.

Medics frantically got to work, trying to start his heart.

Cason lifted Raven and sprinted to a waiting ambulance. The anxious toddler asked her mom, “What’s wrong?”

She couldn’t answer.

* * * *

At Saints Mary and Elizabeth Hospital a doctor stopped Cason at the door to White’s room to break the news:

He was dead.

She went in alone to say goodbye.

A coroner later determined the U.S. Army veteran died of a “cardiac event” triggered by “hypertensive/atherosclerotic cardiovascular disease,” a relatively common heart condition linked to high blood pressure and thickening of artery walls.

While there’s no medical evidence the fight caused his death, a Courier Journal investigation shows that more stringent regulation of amateur MMA could have kept the unhealthy and untrained fighter out of the ring and potentially out of danger. In fact, regulations in 12 other states would have prevented him from fighting.

The investigation, triggered by White’s death 11 months ago, reveals lax, inconsistent regulation and enforcement of amateur MMA in Kentucky and around the country. With more than 1,000 amateur and pro-am shows nationwide each year, the popular sport often draws unprepared fighters willing to risk serious injury as they follow dreams of making it big.

White was allowed to fight despite having high blood pressure. He didn’t get an EKG that might have detected long-simmering heart issues. At a pre-fight physical, he managed to hide what he thought was a broken pinky finger that would have kept him out of the cage. And he could not offer proof he had trained for the bout. In several states, one or more of those factors would have prevented him from climbing into the ring.

The Courier Journal closely reviewed the circumstances of White’s death and explored MMA safety nationwide, examining rules and regulations across all 50 states and interviewing fighters, promoters, trainers, doctors and state regulators.

We found:

• Seven states don’t regulate amateur MMA at all. Six more do so through private “sanctioning organizations,” sometimes authorizing more than a dozen operations that apply a variety of rules.

• Eleven states explicitly require fighters to be trained for a bout or sponsored by a trainer or gym. Larry Lovelace, president of the Wisconsin-based Association of Ringside Physicians, which includes more than 100 members from around the nation, said he knows of fighters who came in “off the street … somebody who didn’t know they were going to be fighting yesterday, and here he is in the ring.”

• Requirements for medical checks differ widely nationwide. Stricter states require such screening tests as EKGs, CTs and MRIs or ban fighters with prior head injuries or blood pressure exceeding set limits. For example, 18 states require EKGs or cardiac tests for at least some groups of fighters. More lenient states like Kentucky have no such rules.

• Many states allow such potentially dangerous moves as striking the head of an inexperienced, opponent lying on the mat. Kentucky allows this even though a neurologist on the state regulating commission, Dr. Tad Seifert, has written about the dangers of concussion and acute and chronic brain injury in combat sports.

White’s opponent that evening is haunted by his memories of the fight.

“The 15th of July, that’s a night that is going to live in infamy with me,” Muse said. “I didn’t get into this sport for what happened.”

Several regulators said states are failing to adequately protect fighters by not having consistent, national safety rules.

Amateurs desperate to further their MMA careers fight for free, and “aren’t so safety-minded. That’s why they need us,” said Leon Ramsey, of the state athletic commission in West Virginia, which regulates amateur MMA.

Ramsey’s state has more stringent medical regulations than Kentucky, barring fighters on blood pressure medications, for example. White would not have been allowed to fight there.

“The states that don’t regulate it, they just let some promoter throw some kid in the ring and get his clock cleaned. These states churn my stomach,” said Bernie Profato, executive director of the Ohio Athletic Commission, one of the first to regulate amateur MMA and one of the more stringent states.

It’s difficult to measure the true toll of non-existent and lax regulation. Officials in 18 states told the Courier Journal they track deaths associated with amateur MMA and 17 said they specifically track injuries.

The Courier Journal found news accounts of six deaths and three near-deaths of amateurs and pros during sanctioned fights nationally since 2007. Three of the four amateur deaths were in states that allow untrained fighters.

“(Some) don’t know nothing about (the sport), and they send them out there,” said White’s girlfriend, Cason. “It’s like the dogs, the pit bulls that you send out there just to go attack.”

Barry Dunn, executive director of Kentucky’s Public Protection Cabinet Office of Legal Services, said the state reviewed the circumstances of White’s death but changed no regulations because of it.

Representatives of Kentucky’s Boxing and Wrestling Commission have not responded to numerous phone and email messages requesting information or comment in the months since White’s death. Seifert asked for questions sent by fax earlier this month but didn’t respond. Todd Neal, a commission inspector, wouldn’t discuss White when approached by a reporter at an MMA event in Covington, Ky.

Dunn said efforts to improve safety must be balanced against such issues as the expense of medical tests, which can cost thousands of dollars, and the need to let amateurs get experience in a state that hosts fewer than 25 MMA events a year.

“Health and safety rules come first and foremost, of course,” said Dunn, who has been with the cabinet since late 2015. “But you also have to make sure that individuals who are just getting their start have that opportunity.”

In 2016, Gov. Matt Bevin replaced a boxing and wrestling authority with the current commission and appointed four members to a related medical advisory board. The commission was to have a “focused vision on unleashing the market conditions necessary to attract world-class professional athletic events to Kentucky and to protect the safety of event participants,” according to a statement at the time.

Dunn said the state beefed up medical regulations, such as requiring more frequent checkups and bloodwork.

Still, Kentucky lags behind many other states in protecting fighters from serious injury. Fighters aren’t required to get EKGs or brain scans; can compete with high blood pressure at a doctor’s discretion; and don’t need proof that they have trained for the bout or are sponsored by a trainer or gym.

“People are getting injured all the time from lack of preparation. They ain’t dying, but people are getting injured a lot in Kentucky,” said Billy Smith, a Louisville-based former fighter and longtime trainer who worked with White for his first fight.

“These guys don’t train … and are getting in there with little knowledge. They get injured or they get hurt. And the athletic commission is letting it happen.

“We need to do what we can (to ensure) the people who are going to get hurt for your entertainment (are) a little bit more protected.”

Untrained and in danger

Smith tried to convince White not to compete on the undercard of Hardrock MMA 90 last July.

“Look, man, you haven’t been training and it’s six weeks away and you’re going to start now?” Smith recalls asking White during a phone call. “If you haven’t been doing much, I wouldn’t suggest it.”

White trusted few people more than Smith. This was the man who had prepped the Akebono Brake worker for his only other bout, which he won by technical knockout in November 2015.

But White’s craving for the adrenaline rush in the cage drowned out his mentor’s advice.

Smith had seen this before.

“A lot of these people will be beat up for your entertainment because they had a dream, or they didn’t have the money or things they need to do what they wanted to do in life — besides work at McDonald’s maybe,” he said.

“So they go out and they try to put together this image of being a fighter, thinking that they would make bigger money in the future and change the future of their life.

“If it means they are going to get hurt, beat on, whatever, for everyone’s entertainment, they will.”

White had loved fighting since he was a 10-year-old sparring with coat hangers in his closet. Figuring he knew the sport, he never trained in a gym for his final bout. Cason said his conditioning consisted of hitting a friend’s punching bag.

Although states generally license trainers, most don’t require fighters to have them or spell out exactly what constitutes training.

In Kentucky, “a lot of times, you know, (untrained fighters) slip through the cracks,” said Gary Thomas, Hardrock MMA’s media director.

That’s even though promoters say the state inspector, Neal, asks around about new fighters’ training regimens. Dunn said if Neal is unfamiliar with a fighter, “I know he starts picking up the phone and reaching out and calling other people and finding out what he can about them.”

New Hampshire is among the majority of states that don’t require training for a bout. John Hagopian, a deputy commissioner of the boxing and wrestling commission there, said amateurs “don’t have to have anything in the way of experience.”

Lovelace, the ringside doctor who also serves on the Oklahoma State Athletic Commission, said untrained fighting is “extremely dangerous” and should never be allowed. But he said he understands why it happens: Amateur fighters struggle to afford training in a reputable gym and promoters want a large roster of fighters.

Regulators must be on guard, said Jody McCormick, executive director of the Alabama Athletic Commission.

“We have people all the time coming to us wanting to fight, and there is only a certain amount of vetting we’re able to actually do on these guys, especially in MMA,” McCormick said. “We have to be very, very careful what we allow with these fighters.”

Alan Taniguchi, executive officer of the body that oversees amateur MMA in Hawaii, said an amateur fighter without a trainer or gym “raises red flags.”

“But they’re adults,” he said. “It would be stupid to step into an MMA fight if you don’t know what you’re doing.”

White’s opponent on that fatal night was fighting in his first bout. Unlike White, Muse was trained and believes everyone should be. He teaches other adults in his own dojo.

“Mixed martial arts — especially fighting in a cage — it’s no joke,” Muse said. “We’re grown men, so we know the risk when we step inside that cage. I’ve got students of my own that I work with here, and before the fight I (tell) them anything can happen when that door locks and that ref says, ‘Are you ready?’”

Ready to rumble?

White’s pre-existing health problems may have been caught more easily in states other than Kentucky.

At least two physicals are required to fight in an MMA bout in Kentucky. One is part of a licensing process that also includes paying $25, filling out an application and indicating the ability to “compete without the risk of serious physical injury.”

A second exam is done just before a bout.

Neither exam requires an EKG, which can help doctors spot signs of heart disease and is one of the tests used to detect White’s condition. An EKG is not required in Kentucky unless the medical advisory board decides it’s needed in a specific case.

Connecticut, Massachusetts and Kansas, by contrast, require EKGs or “cardiac testing” for all competitors. Fifteen others, including Utah, Texas and Pennsylvania, mandate the tests for specific groups such as older fighters. White, at 37, would have qualified as an older fighter in those three states.

Kentucky screens for cardiovascular problems through blood pressure checks, letting doctors decide what’s too high. Nationally, Lovelace said, high blood pressure, or hypertension, is “probably the most common reason to disqualify a fighter.”

But White – whom Cason said was unaware of his heart condition – was cleared by two medical professionals: A nurse practitioner after a physical a few weeks before he died and the ringside physician.

The nurse took his blood pressure as he stood upright, recording 148/90, above the normal 120/80, according to records obtained by the Courier Journal. The nurse noted a high result after 100 hops, a test of physical exertion. White’s hypertension was also specifically noted by the nurse. It’s unclear whether he was taking his prescribed blood pressure medicine.

Dr. John Harris, a cardiologist with Norton Heart & Vascular Institute who didn’t know White, said if a patient came to him with a reading of 148/90, he would likely follow up with an EKG or heart ultrasound and ask the patient to hold off on strenuous activities until he knew what was going on.

Dunn defended Kentucky’s medical rules as stronger than what existed previously. Before 2016, he said, the only required exam was done just before the bout, and blood work was only submitted once per year. Now, in addition to two physicals and a post-fight check, fighters must submit blood work within 180 days of a fight. Those older than 35, like White, are subject to “individual consideration” by the medical panel.

Hardrock’s Thomas described Kentucky as “customer friendly” compared with surrounding states. Dunn said the state must consider costs when setting rules.

“We’ve had a lot of pushback on (the cost) front,” mostly from amateur fighters, Dunn said. “We have to draw the right balance in making sure the public safety is met while not making it so cost-prohibitive that it’s impossible to fight.”

Officials elsewhere agree. Taniguchi said Hawaii doesn’t require EKGs because “they are very expensive,” more than $500 for some patients.

“I personally wish we could have them all take the test,” Taniguchi said, “but then no one would fight.”

Massachusetts, one of the strictest states, requires across-the-board EKGs, dilated eye exams and even a brain scan within five years of a fight. The state also requires training.

Still, amateur fighter Rondel Clark died there last year from something even the most stringent pre-fight physical couldn’t have picked up — a rare condition called rhabdomyolysis, the rapid dissolution of damaged skeletal muscle. A medical examiner determined it occurred after blunt impacts to the head, an MMA hazard in any state.

Life without Daddy

With fighter safety at stake, Dunn said the boxing and wrestling commission in Kentucky reviews all policies “more often than what is required by state law.”

After White’s death, he said Kentucky officials considered the adequacy of their rules and whether they were followed.

“We looked, and for example, our regulation requires that there be an ambulance on the scene. Well, there was. Our regulation requires an EMT on scene. There was. Our regulation requires a physician there at the ring. He was,” Dunn said.

“Everything was there,” he said. “It was one of those things that is just so unfortunate because it was all there. There was just nothing that could be done.”

Cason is now building a life without the father of her child. She doesn’t get to visit White’s grave very often because he’s buried near family in Texas, where more than 100 people attended his funeral.

Their daughter, now 3, is doing better these days. But Raven misses her dad and carries his photo wherever she goes.

“She holds the picture up to show people,” Cason said. “And then she’ll tell everyone that her daddy is in the sky.”