Health Explanations for Motivated Patients: Your Checkup
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Health Explanations for Motivated Patients: Your Checkup
Pulse Oximeters May Fail People of Color: What You Need to Know
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We investigate how pulse oximeters – those small devices that clip onto your finger and measure oxygen levels – can show bias against people with darker skin tones. This critical medical tool may overestimate oxygen readings in Black patients, potentially leading to delayed or inadequate treatment.
• Pulse oximeters use infrared light to measure blood oxygen, but melanin in darker skin can scatter this light and cause inaccurate readings
• Studies show Black patients are nearly three times more likely to have hidden low oxygen episodes missed by pulse oximeters
• During COVID-19, this bias became particularly dangerous as oxygen readings determined critical treatment decisions
• Most pulse oximeters were originally calibrated on light-skinned individuals, with minimal diversity requirements
• The FDA is now developing better standards requiring more diverse testing groups
• This issue extends beyond pulse oximeters and reveals broader systemic healthcare inequities
• Medical practitioners need to consider the whole clinical picture rather than relying solely on pulse ox readings
Stay healthy, my friends, until next time.
Production and Content: Edward Delesky, MD & Nicole Aruffo, RN
Artwork: Olivia Pawlowski
Hi, welcome to your checkup. We are the patient education podcast, where we bring conversations from the doctor's office to your ears. On this podcast, we try to bring medicine closer to its patients. I'm Ed Dolesky, a family medicine doctor in the Philadelphia area.
Speaker 2:And I'm Nicole Rufo. I'm a nurse.
Speaker 1:And we are so excited you were able to join us here again today on what is a very special, important episode, where we are going to talk about something that involves many of us patients, even clinicians and, honestly, it's been trusted for decades and it's called the pulse oximeter. It's the little device that clips to your finger and tells you your oxygen level, and something that is coming to light and that's been known for a while this article came out in June of 2024, and we're reviewing it this year, one year later is that the pulse oximeter may not tell the same story for everyone, and so it's something important that we're talking about today, and one important question we're asking is can a device be biased? And the answer, seemingly shockingly, is yes, and so today we're going to talk about how pulse oximeters may overestimate oxygen levels in people with darker skin tones and what that means for the health of for you or your neighbor or a loved one, and the health care system as a whole. So, nikki, can you tell us what is a pulse oximeter?
Speaker 2:So a pulse oximeter, or otherwise known as a pulse ox, which you may have heard, is a small device, usually a clip, where it can be a little sticker that goes around your finger. You can put it on a toe, an earlobe, but it shines. It has that red light, that's an infrared light that shines through your skin and it measures how much oxygen is in your blood. It's a critical tool in hospitals and doctor's offices, even at home. I mean you can like buy them on amazon or get it at a pharmacy and people can use them daily to monitor their oxygen levels and it's a pretty like.
Speaker 1:I mean people like depend on them for valuable information right, because I mean, like this is, it's a vital sign and important clinical decisions are made. I mean, I was in the office two weeks ago and I was thinking, based on this number, I'm going to decide whether this person goes to the hospital or not. Yeah, those types of decisions are made every day with the pulse ox. Or is this person who is in the hospital ready to go home? Does this person need oxygen at home and completely reshape their lifestyle? And so this article that we're reviewing today kind of indicated that there is a history of inaccuracy, and they highlight several stories. The first red flag about bias in these devices came about 30 years ago, and back in 1990, researchers found that pulse oximeters tended to overestimate oxygen levels in black patients compared to white patients, and that means that device might say oxygen level is fine when actually it's too low. Despite follow-up studies in the early 2000s, these warnings didn't get much attention and what really happened is that it took COVID to actually really put this into notice.
Speaker 2:So during COVID, which you may remember, you may remember oxygen, accurate oxygen readings were pretty much everything and critical. Like you were just explaining how that could determine if someone went to the hospital, or maybe if they were in the hospital or if someone was intubated during their admission. Um, but the university of Michigan did a pretty big study in 2020 where they discovered that black patients were nearly three times more likely to have these hidden episodes of low oxygen, even if their pulse ox was reading like it was normal. Um, so that means that they were three times more likely to have a low oxygen missed.
Speaker 1:That's a lot.
Speaker 2:And so, because of that, someone was either not getting the supplemental oxygen that they needed, or maybe they were admitted to the hospital later, when they were a little bit more compromised and more sick, which those delays could be life-threatening and unfortunately probably were.
Speaker 1:Yeah, and so one big question is why does this happen? And so pulse oximeters work by sending light through the skin, but melanin, the pigment that makes skin darker, can absorb or scatter that light, and so the devices were originally calibrated decades ago, often tested mostly or completely entirely on people with lighter skin, and even today, some devices are approved without clear evidence that they work across different skin tones, and so there was another recent investigation that found 25% of pulse oximeters approved after 2016 didn't mention skin tone testing at all, and the FDA, until recently, their guidance only suggested testing on two dark-skinned individuals or 15% of a study group. It wasn't required or standardized, and so this technology was really set up for blind spots, like literally. And so what is being done about any of this? Because this is massively important.
Speaker 2:So the good news is that, since 2020, the FDA has prioritized this issue and they've been working with scientists and these device companies to develop better standards, with newer guidelines expected to require a more diverse group of test subjects. I don't know why they didn't do this 30 years ago, but that's probably a whole another whole discussion.
Speaker 2:Yeah literally Discussion Racism, yeah, literally. Engineers are also working on smarter technology, such as a dual ratio, optical systems that may adjust readings based on individual tissue differences, but not quite ready for widespread clinical use yet. Not prime time, mm-mm. So, unfortunately, until all of these new rules are in place and new devices are on the market, this is where we are.
Speaker 1:Yeah, and still using the old technology that was known to be flawed, that study where it was three times more likely. They found that in white patients, the discordance between an arterial blood gas and the pulse ox was 4% in white individuals and 12% in black individuals, to put that number into a little bit more context. And so where does it leave us? That's a tough question. I know we have a lot of patients here listening and it's something to just keep in mind when you're advocating for yourself. We don't rely on one number.
Speaker 1:You look at the whole clinical picture as one thing, as a doctor and whoever's taking care of patients, and this really just calls into light that we need to be more aware of bias in medicine. This calls into a much bigger picture that bias in medicine doesn't limit itself to medical devices. It's not just a technical flaw. This was done because of bias. All of the testing was done on white patients in the beginning because of bias, and this is a systemic equity issue.
Speaker 1:For those listening who might not understand what equity versus equality is equality being the thought that everyone gets the same thing and equity being the thing that everyone gets what they individually need to raise them up, and so it's Really a reminder that what's standard quote unquote in medicine often has left out people of color. And fixing it isn't just about updating technology, it's about updating how we think and how we design and how we regulate our entire healthcare system. And the pulse ox is just a little, very tiny, tiny tip of the iceberg about what is a much deeper, widespread issue. I mean, this came up, this is in calculators, this is in the ASCVD, the cardiovascular risk score, where there is a toggle for whether someone is African-American or not in the score. Or another one I can think about is kidney function.
Speaker 2:One I can think about is kidney function, old kidney scores for egfr, which is the amount of flow that, like measured going through your kidney included whether you were african-american or not, and this is so now I'm thinking of because there have been a few times where we had like a rapid on a kid and like their blood gas came back and like the oxygen level was different than the monitor.
Speaker 1:Yeah.
Speaker 2:Which, honestly, like a pulse ox, isn't perfect regardless of what color skin you have, especially on a kid, Like if you wiggle your tail. It's like you know crazy. But yeah. Yeah, cause, like, yeah, like crazy. But yeah, yeah, cause, like, yeah, like the blog guys will come back. I'm like, oh, that makes sense why you look so punky. Yeah, even though you're you know the monitor was reading your. It was like 95 or whatever.
Speaker 1:It's, it's everywhere. I mean, like reading this, it makes me roll back and call into question of, like tons of situations. It's a lot and it's important and so now, if you're listening to this, you could be mindful for yourself, a loved one or a neighbor. I kind of stole your thunder there for a second.
Speaker 2:Yeah, you did. It's okay, I'll let you have it.
Speaker 1:Thank you for coming back to another episode of your Checkup. Hopefully today you were able to learn something for yourself, a loved one or a neighbor. Find us on our website to find our old episodes. Follow the podcast so that you can get updates about when future episodes come out. You can find us on Instagram. We're very active on threads, if you like text-based social media. Still, it's what Twitter basically used to be. Most importantly, stay healthy, my friends, until next time. I'm Ed Dolesky. I'm Nicola Ruffo. Thank you and goodbye, bye, bye. This information may provide a brief overview of diagnosis, treatment and medications. It's not exhaustive and is a tool. Thank you, provider, for personalized guidance based on your unique circumstances. We explicitly disclaim any liability relating to the information given or its use. This content doesn't endorse any treatments or medications for a specific patient. Always talk to your healthcare provider for complete information tailored to you. In short, I'm not your doctor, I am not your nurse, and make sure you go get your own checkup with your own personal doctor.
