Critical care
profession is moving on from discussing the issue without properly addressing it. Although NHS England and the MHRA have published guidance informing the public of the problem, advising them to pay more attention to pulse oximetry trends over time than singular readings, there has been no equivalent update for doctors and nurses. “Yes, patients need to be made aware, but so do healthcare professionals,” says Dada. “And that's one thing that I’d say actually hasn't been amplified since the release of our report. If a patient is saying, ‘I am not confident in this device's reading at this time,’ a doctor who isn’t aware of the fact that such significant deviations exist might just dismiss their concern. What’s the point of patients becoming more aware if doctors are not adapting or adjusting their practice accordingly?”
A more complete picture
The problem, as Dada sees it, is that doctors don’t understand how they can use Sjoding’s findings to better serve their patients. Currently, it’s easy to think of this as a problem without a solution. There’s no similarly cheap and non-invasive replacement for today’s devices, and abandoning them would be counterproductive. In a recent pre-print study, at-home use of pulse oximeters after a positive Covid test lowered the risk of death by 52% in South Africa. As the APSF also stresses: “It is potentially more harmful if the known bias in measurement related to skin tone resulted in a lack of confidence in pulse oximetry as a monitoring tool for patients with dark skin tones.” Depriving patients of diagnostics based on the colour of their skin is no way to address inequality. So, doctors need to be sceptical of pulse oximetry readings without lacking confidence in pulse oximeters themselves. That’s not an easy balance. “One of the challenges is the practicality of what this means,” points out Dada. “What does it mean for our practice, for our patients, for us? In terms of how we’ve been practicing medicine, this is all we’ve known.” For Sjoding, simply being mindful of those questions can be productive. “My sense is the pulse oximeter has become so ubiquitous, and we’ve become so comfortable using it, that we’ve forgotten that it’s not perfect,” he says. “Most of what we have in medicine is imperfect, but we’ve taken it for granted.” He’s not going to stop using tools that provide valuable information so rapidly. “But I have a much greater awareness that, when the pulse oximeter is reading a value like 92%, the range of what that could actually mean is much wider than I previously appreciated, particularly in black patients.”
Although Sjoding is now less reliant on the tool with which his specialism is arguably most associated, his new approach is still true to his training. “I think a lot of what we do in critical care is synthesise information,” he continues. “One or two pieces of data that you have may be imperfect, or most of the data,
Practical Patient Care /
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but when you synthesise it all together, you get a more complete picture, and you’re less likely to be influenced by one thing that's off.” Similarly, Dada notes that her threshold before doing an ABG for darker skinned patients with breathing difficulties is now lower than it might be otherwise. Of course, in the most strained scenarios, that might not count for much. Stretched resources might put anything other than pulse oximetry readings out of reach. In the early stages of the pandemic, pulse oximetry readings were prized as the ideal biomarkers for rapid clinical decision-making, meaning some patients were wrongly sent home or denied treatment that hospitals were equipped to give them. That does not need to happen again. With investment and attention, pulse oximeters can be adapted and improved. As Moran-Thomas points out in a follow-up piece in Wired magazine, 1970s Hewlett- Packard ear oximeters were specifically designed to work the same way across all skin tones, body types and disease states. Similarly, Sjoding’s data does not indicate how different pulse oximeter brands and models perform, leaving open the possibility that certain designs in use today are more equitable. Even before those questions are answered, or new models become available, however, Dada wants practitioners to realise that “there is something that can be done”. Like US and UK-based critical care trainees Daniel Colon Hidalgo, Olusegun Olusanya and Emily Harlan, who recently published a letter in The Lancet, they can press for change to how pulse oximeters are tested, approved and purchased. Like Dada herself, they can discuss the issue with their colleagues, using both research like Sjoding’s and individual case studies. Before that, “it can start with your interactions with your patients,” she says: “just sharing your awareness that these devices may not read as accurately for certain people and responding accordingly.” The few seconds that takes could change everything.
Pulse oximetry readings were ideal biomarkers for rapid decision making during the pandemic.
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