In out-of-hospital (OOH) care, particularly in remote or wilderness settings, clinicians have fewer tools to gather assessment data. Accuracy with the basics is a cornerstone of education and training for decision-making and transportation of the sick and injured. In that context, it’s time to reconsider decision-making around skin color as a variable in our data collection. Early in the assessment pattern we teach students to form a general impression of the patient. Are they sick or not sick, hurt or not hurt? Could an adjustment in our skin assessment education and training could make our general impressions and early recognition of acute illness more accurate? Is it accurate to describe human skin as “Pink, Warm and Dry” as a normal baseline for skin color, temperature, and condition? Is it accurate to describe shock in all humans as “Pale, Cool, and Clammy”?
Let’s move beyond a narrow understanding of skin color signs to be more holistic in our approach and use science and an understanding of human diversity as our guide.
Lets teach that skin color could demonstrate varying degrees of melanin richness which can demonstrate or conceal injury and illness. When assessing skin color, look at the face, neck, oral mucosa, and the palmar surface of hands and feet as well as nail beds. A look at the patient’s core color in comparison to peripheral color is helpful in our understanding as we are looking for peripheral versus core perfusion. For most of our decision-making, color may be less informative than the patients skin temperature and moisture. OOH clinicians look for shock starting at the first “hello”. We continue to look for data that confirms or disproves shock until we transfer the patient. What is normal for the patient? Are there friends or relatives of the patient that can comment on whether the patient’s skin tone looks “normal” for them? Is it possible that the terms and documentation for normal skin condition changes from “Pink, Warm and Dry” to “Normal Color, Warm, and Dry”?
Let’s also advocate for teaching resources that reflect this patient diversity. As per a 2021 study, less than 19% of photographs in dermatology textbook documented diseases in skin of color. Another study showed that among professional dermatologists, nearly half felt their training specific to people of color was inadequate.
A person with melanin-rich skin in anaphylaxis may not present flushed, and hives and rashes may only be apparent with close observation and touch. The same person who is in shock with poor perfusion may present with gray or yellowish-brown skin in color rather than bluish.
Emergencies arising from the loss of core body temperature (hypothermia) and elevation of core body temperature (hyperthermia) have associated color changes in OOH curriculum that do not match skin colors for patients with melanin-rich skin. We may need to expect that color change in skin of color may be delayed as compared to pale skin and may not develop as blue or red in color as a response to core temperature changes.
While central cyanosis is a late sign of respiratory insufficiency, it may not appear in a person with melanin rich skin. Gray or cyanotic fingertips may be more common in these populations. The absence of cyanotic skin could create a false sense of the patient’s condition.
When a patient has been involved in a traumatic accident, we train our students to provide a rapid physical exam after bleeding control to assess for large injuries and shock. Bruising in persons with melanin-rich skin may have a delayed presentation in color change (or change that may be harder to detect) and may be challenging to discern. Palpation of the skin is necessary to determine temperature and texture. Bruising and swelling may require symmetric comparison to uninjured parts of the body and in addition to tenderness, may present as lumpy and warm during palpation.
We train our OOH students to assess pupils as they assess other vital signs and commonly use the mnemonic “PERRL”. Normal pupils are equal, round, and reactive to light. We associate a brisk pupillary response with an intact nervous system. We teach our students to look for sluggish pupil responses and unequal responses as a sign of concern. We will need a brighter light to assess pupillary response with patients whose irises and pupils provide less contrast. Ambient light may not be strong enough to accurately gain this assessment.
We teach our students to use a finger probe pulse oximeter to assess for oxygen saturated hemoglobin. In the last decade, this tool has been included in the primary assessment at the EMT level and following the COVID pandemic, it is often used by laypeople as well. Pulse oximeters (or “pulse ox”) work by measuring the impedance of light through the skin and tissue. We teach our students to remove fingernail polish and possibly warm the patient’s hand and fingers before use to help adjust the error of these devices. We will need to further evaluate the effectiveness of this tool for melanin-rich skin. One recent study showed reduced effectiveness of pulse oximeter’s ability to read through melanated skin and an association between these limitations and comparatively reduced rate of oxygen administration of oxygen in those populations. Some manufacturers are aware of this consideration, but not all pulse ox brands are held to the same standard of testing on darker skin.
Are we prepared to update our practices in initial medical education for OOH care given these realities? Our first exposures create an unconscious bias. Our foundations of knowledge are the cornerstones from which we build. Let’s update curriculum, printed materials, and testing to reflect accurate data that includes a spectrum of human skin tones. Let’s continue upgrading our photos and images of injuries and illness we share with students to include all colors of humans. Ultimately, we need to update our teaching resources, techniques, and the research underlying them to more properly complete the task we all share: treating as effectively as possible all the patients we encounter in OOH environments.
Online Resources for Assessing Rich Melanin Skin