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Understanding Oxygen and the Apple Watch 6: A Primer on Oxygen Saturation 101

The tech world has had a hold on the imagination and pocketbook of Americans for decades, improving our day to day communication, entertainment and educational options, all contained in the device we hold in our hands. More recently, tech companies have entered the multi-billion dollar health and wellness market, claiming a roseate outlook on life quality by revealing a wealth of “health” data populated on our iPhone or Android phones for us to peruse. For those that majored in business, art, political science or philosophy in college, watched “Keeping Up with the Kardashians” instead of “Mr. Wizard” reruns and did not take a physiology or human biology course, these numbers may be bewildering. It is time to let some “air into this room” and provide a background for understanding tech and health devices.  After 4 decades around EKG’s and pulse oximeters attached to humans and a user of Apple products for almost as long, I will provide the introductory course on the latest Apple foray into health: oxygen saturation and the pulse oximeter.

Oxygen is a key to human health. Before it’s atmospheric debut, we had bacteria for a billion years with few tech inventions during this period, save for the flagella, a whip like structure that could take you a few inches across a scum filled pond. Queue the plants (algae and other photo-synthesizers) and oxygen enters the atmosphere allowing for multicellular organisms and ultimately us (now is the time to hug your house plant out of gratitude). What did oxygen do for us? It unlocked the ability to generate much more energy from food sources that allowed us to dig a ditch, launch a satellite or use your TV remote. As any biochemistry or medical  student knows, ATP, the powerhouse chemical we use to store and release energy, is manufactured 16 fold in the presence of oxygen (for the curious, see oxidative phosphorylation and electron transport chain for more details).

The engineering dilemma that evolution was faced with for us multicellular beings was a supply and distribution problem. How to get oxygen from the air to each of our cells?  To move a substance, you need a pressure gradient to drive the work and the atmosphere pressurizes oxygen to move from high to low pressure zones. But this does not get the prized element to deeper tissues. For that obstacle, we evolved the lungs, blood vessels, blood and heart to circulate oxygenated blood to tissues to bypass this problem. 

Yes, blood, that substance thicker than water. Oxygen can dissolve in blood but at very low concentrations. To improve on the quantity of oxygen, we inherited the red blood cell and its key constituent, hemoglobin. Hemoglobin is the main oxygen carrier in the blood and allows pick up and delivery of 02 to the tissues. Oxygenated blood is bright red (usually arterial) and less oxygenated blood (usually venous) is blue. We can exploit this light absorbing property to determine how much oxygen is bound to hemoglobin at a particular moment by shining a frequency of light at a blood vessel and checking how much is absorbed and reflected at one time in the heart beat cycle.  The ratio of oxygenated to  de-oxygenated hemoglobin is measured, and reported as  oxygen saturation.

Do you need a device that warns you of oxygen shortage? Shouldn’t you feel short of breath, breathe faster and get yourself into an emergency room in time? Not always, as your brain, highly dependent on oxygen, can go haywire with  confusion, lethargy and poor judgement as a consequence. This is why the flight attendant always directs you to put your oxygen mask on first before your children. What about turning blue (cyanosis) from low oxygen? Unfortunately, this is a late occurring sign which occurs when fully ⅓ of the hemoglobin is devoid of oxygen.

Is there an early warning device to warn us of oxygen deprivation?Cue the pulse oximeter:  oxygen saturation can be measured by a pulse oximeter, or more recently with tech watches that have similar technology. Healthy lungs at sea level usually allow for oxygen saturation over 95%. As with all technologies, certain pitfalls apply. If your hemoglobin is abnormal it may not be measured properly. Carbon monoxide poisoning, for instance, renders hemoglobin incapable of binding to oxygen but is not registered by the pulse oximeter. Yes, you can asphyxiate with a normal pulse oximeter reading. The sensors must be close to the skin and not moving or else a faulty reading could result. Even expensive devices can be subject to error. Many a time in the surgery center, a reading of 60% could appear in an awake, non sedated patient. Repositioning the sensor, recalibrating the device or wheeling a new machine into the OR solved the false reading.

So what can you glean from the result? High altitude can lower oxygen saturation due to lower oxygen pressures. Altitude sickness can result with headaches, shortness of breath and in extreme circumstances, flooding of the lungs with fluid. Severe pneumonia can lower oxygen saturation and in the case of COVID 19, may not result in air hunger which would normally warn you of severe lung infection. Severe asthma could also cause a drop in oxygen saturation. Apple has started a research trial examining the usefulness of the Apple Watch 6 in this circumstance.

 The most important use of this technology may be in screening for obstructive sleep apnea. This condition is quite common in the U.S with a prevalence up to 30% of males and 15% of females).  Celebrities such as Rosie O’Donnell, Shaquille O’Neal,  William Shatner, (aka Captain Kirk of Star Trek fame), Quincy Jones, Randy Jackson (of American Idol fame) are afflicted. Luminaries whose death may have been influenced by sleep apnea include William Howard Taft (former 27th President), Jerry Garcia (of the Greatful Dead), Justice Antonin Scalia, Carrie Fisher (of Star Wars fame) and James Gandolfini (of Sopranos fame). Sleep apnea has severe health consequences and has acceptable, effective therapy. With the increase in risk factors such as adult obesity and sedentary nature of the population, obstructive sleep apnea is becoming epidemic, resulting in upper airway obstruction at night with snoring, interruption of breathing and dangerous reduction in oxygen saturation. This condition often results in headaches, daytime fatigue, hypertension, acceleration of cardiac disease and premature death. A continuous positive pressure mask can ameliorate this condition. A convenient, readily available screening tool such as a reliable pulse oximeter for nighttime use could potentially save multiple lives by directing those into the office of sleep specialists for definitive diagnosis and treatment.

So should you climb on board the day and night pulse oximetry tech train?  With certain caveats (a device that has reproducible results and matched to gold standard testing, FDA approval and  that works for night-time monitoring) this metric may benefit you when hitting the ski slopes and when your significant other has had it with your snoring and asks you to “do something about it.” Take a deep breath and ponder that.

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The Battle Against Fake Science

The fates of Dr. Li Wenliang and Dr. Anthony Fauci will be irrevocably linked in our current times. Both physicians were muted by their respective political overlords:  Dr Wenliang sacrificed his life in the pursuit of warning the world of a deadly airborne virus originating in Wuhan, China and Dr Fauci, by the Trump Administration in thwarting his public health efforts in limiting morbidity and mortality. In these unsettling times, the assault on medicine and public health is not only lethal, but tolerated by industry, public opinion and political factions. 

When capitalism and profit intersect with human health, the American experience has often been in the favor of the former. American medicine in the 19th century was profit driven, fueled by several hundred medical schools that had no legitimate science curricula, no formal training programs and no criteria for competent professors. US medical students, desiring a top flight education, would journey to Paris to get state of the art instruction. Snake oil salesmen who peddled dangerous potions for multiple ailments thrived in the 19th century. 

The 20th Century provided some sanity and sanctity in the pursuit of science and healthcare. Abraham Flexner, an American educator, at the request of the Carnegie Foundation, reported in 1910 on quack medical training that resulted in the closure of multiple schools and began the scientific basis of medical education in the U.S. The Food and Drug Administration, established in 1906,  provided an oversight of drug therapy and provided a safety net to the general public.

Greed and the pursuit of profit in healthcare today still cannot be denied.  Popular entertainment reinforces the profit motive. Mr. Wonderful, on Shark Tank, when reviewing a vitamin and herbal supplement, gleefully queried the proprietor, “I don’t care if it works, what are your yearly sales?” Gordon Gecko, in the 1980’s movie “Wall Street”, uttered “Greed is good.”  Even in the 1950’s, Jim Anderson,  the iconic principled father in “Father Knows Best” sitcom during  the Eisenhower era, readily endorsed the Springfield snake oil salesman’s request for a business license because he was good to his dog and family. 

Congress got into the act of greed and greenbacks in response to a potential flood of pharmaceutical lobbyist money, further sacrificing the principles of science and public safety. Utah Senator Orin Hatch orchestrated potential legislative medical malpractice with The Dietary Supplement and Health Education Act of 1994 (DSHEA) which decreed that over the counter supplements and herbal products did not need to prove safety data prior to their release to the public and any complications would only need to be voluntarily reported. The supplement companies could not claim to treat a “disease” but misleading euphemistic claims such as “supporting health, “wellness,” or supporting a biologic system could be used in advertising without any scientific data to confirm the claim. What was the result? The OTC industry money profits increased from $9 billion to $50 billion,  Salt Lake City, Utah became a destination for the supplement companies. Hatch’s family became lobbyists for the industry and he and other members of Congress had a reliable flow of campaign donations.  What did the consumer get? The answer is clear: A flood of products that resulted in liver injury, life threatening drug interactions and occasional cardiovascular deaths. Product labeling was often misleading or wrong. Probiotics, living bacteria that can contribute to health, were often non viable or absent when analyzed by microbiologist/scientist scrutiny (R. Knight, UC San Diego). Families put themselves into financial jeopardy by spending hundreds of dollars per month on bogus supplements hawked by salesmen and health providers. This was a legislative fiat that legally supported medical quackery.

Now the technology industry is attempting to expand their profits by tapping into our health obsession and circumventing health law. Products that evaluate sleep hygiene, pulse and heart rhythm and oxygenation are entering watches, phones and bracelets. When developing a new technology, the rational response is to compare your experimental device to a gold standard that accurately measures the outcome you are looking at. For sleep analysis this is polysomnography, a medical test that looks at EEG, respiratory rates, eye movements among other data; oxygenation gold standard is the transmission pulse oximeter. Tech companies, such as Fit Bit and Apple, for instance, bypass the gold standard test and support their device results with an opaque “secret artificial algorithm.”  In the few studies that compare products to their gold standard, they are often shown to be inaccurate. The companies, unable to get FDA approval, then take guidance from the supplement industry by using “wellness” as the reason for the biometric. With no reproducibility and no public direction on the meaning and actionable explanation for the results, we are left with tech company advertising babble to encourage their purchase. 

It has been the pandemic of 2020 that has shown the stark reality of science deniers. Trump’s effort to undermine science and mask wearing and the infiltration and destruction of our beloved NIH, CDC and FDA autonomy has been an armageddon moment in healthcare. Pushing hydroxychlorquine, megavitamins and experimental medications that have not been fully vetted in randomized controlled studies as effective cures is unacceptable to the medical community and cannot be recommended as treatments to the public at large. Furthermore,  anti-vaxers, and proponents of the deadly “Herd Immunity” strategy are further evidence of our dilemma.

I am reminded of Dr. John Snow, a British obstetrician in the mid 19th century, who observed his London patient washing her infant’s diapers in a common water pump in town that spread cholera throughout the community. Snow’s work established the water-borne source of cholera and his urging of removing water pump handles. His pleas went unheeded by the public and scientists of his time leading to the death of thousands of additional victims in the cities around the globe. Accepting well designed investigations and their conclusions are our only way to avoid a “Dark Ages” outcome of health goals.

Our hope for the future lies in the investment of science teachers, high quality training of physicians and allied health providers, debunking and removing dangerous healthcare products on our social networks and providing the public with political leaders who want to move away from the past and into the evidenced based medical world of the present. 

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How Did Trump Happen?

As the key engaged the heavy deadbolt, a loud clank was emitted and the solid steel doors opened the locked ward of the LA County Psychiatric Hospital. That sound and the antiseptic smell of the unit still linger 35 years later, as I walked across the threshold, as a third year medical student, ensconced in my newly pressed white coat and brand new Washington Therapeutics manual.  A large muscular man was leaning on a table brooding and muttering to himself. The psychiatry resident pointed to him and asked me to take a psychiatric history. “He took a bus from Illinois and was arrested on the 405 Freeway while attacking cars on the off ramp with a crowbar.” After eliciting some grunting responses and “God directed me” responses to my clinical questions, I abandoned my medical questioning. “Send him to my office and I’ll demonstrate how to perform a psychiatric history,” my instructor demanded. Summoning the patient into the small office, I sensed a catastrophe in the making. Turning over the psychiatrist’s desk and chairs and uttering a string of expletives in rapid fashion, he stormed out of the room.  The resident paused for a minute and then observed, “That guy is dangerous. F**k the history. Double his haloperidol dose.”

This moment in my medical training recurs in my mind as I watched for the past 3 ½ years at the news correspondents’ quizzical looks as they tried to respond to Donald Trump’s ever increasing disjointed communication.  While my patient in the county psych ward communicated with violent behavior, he nonetheless was unable to express a coherent on-topic conversation that mirrors reality like Donald Trump.  As the evidence mounts of Trump’s psychopathology,  supported by Ivy League and family embedded mental health specialists, the parallel becomes more realistic.

How can you account for the election and sustained authority of a man that has no appreciation for reality, no empathy and no problem solving ability? Three concepts are critical, in my opinion: 1) The firewall of falsehoods that support politics and insulate the economic, profit motive for governance; 2) the pseudo-reality of 7 decades of television watching; 3) the inability of rational people to respond to a psychotic dialogue.

The political firewall of falsehood is particularly thick in our early education. We learn that Thomas Jefferson, the author of the Declaration of Independence and the third president of the United States is a great American, however educators skim over his ownership of slaves.  Andrew Jackson, our “people’s president” and victor over the British in New Orleans during the War of 1812, was also the architect of the forced removal and slaughter of the Cherokee from Georgia despite two Supreme Court rulings against its legality.  Various wars fought in the name of preserving the American way of life were often a subterfuge for economic gain. The latter was particularly relevant for me during the Vietnam War, as my generation was drafted and conducted the war at the bequest of past presidents, including the corrupt Richard Nixon. The firewall called the war effort to “prevent the spread of communism” and contain China and Russia from world domination.  These pseudo-facts were debunked by Southeast Asian historical scholars and disseminated in political science courses during my college years and validated by the subsequent arc of history.  Profits and employment opportunities in the U.S. were the nested reasons for this conflict. Lobbyists dominate political decision making and mask the true reason for congressional and presidential decision making. When one does break the firewall of mendacity and falls on the other side, the lure of profiteering can steer you back to the wrong side. No wonder, during my one Vietnam era protest in Washington, I was warned by relatives that this could harm my future employment in Wall Street financial firms. It was hard to contest the Trump supporter’s claim that “all politicians lie.”

Television was the final coup de grace that catapulted Trump into the White House. The lack of critical thinking is pervasive in our society and television has obliterated the lines of news and entertainment. Early television could still cling to morality and group cooperation (think Father Knows Best and Gilligan’s Island). “Reality” shows that masquerade as truth created a fictional narrative that viewers accepted without reservation. Without The Apprentice, Donald wouldn’t have had the political on-ramp he enjoyed.  While all who worked with Trump in the real world of construction and media declared him a fraud, he was on television and they must be mistaken.

In summary, rational people brought up on falsehoods, ensconced in Reality TV  for a number of years combined with protective self-talk when confronted with uncomfortable behavior from elected leaders, begin to accept and adapt to irrational discourse and actions. Consequently, they excuse or ignore it.

So the narrative goes as follows: Yes, he tells lies, but don’t all politicians do the same (the firewall of falsehood) and he’s a competent businessman, it says so on television. The psychosis element is dismissed by either: 1) not dealing with it (think of how many people avoid the homeless);  2) he couldn’t be in his position with a diagnosis of mental illness.

Mental illness that erupts into violent and dangerous behavior is easy to discern and react to swiftly with isolating the perpetrator from society.  That was easy to understand in my early days of training. Like the frog slowly boiled in hot water,  we have as a society built a firewall from truth, televised abnormal behavior into entertainment and have been trained to look away and excuse or normalize statements of question or actions by leaders when confronted with uncomfortable behaviors.  My Uncle Jack use to respond to all inexplicable government driven situations with, “It’s Fixed.”  I think he is correct, but it is up to us to fix the fix.

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Portland Exposed

Asian Dumplings from Afuri Ramen and Dumplings

Xylophone Recital at the Trailblazer Game

  • Food truck in Pioneer Square
  • Voodoo Donuts
Multnomah Falls

One of the perks of retirement is opening up a map, seeing a destination you’ve never been to and then booking it. I had never been to Portland and was curious if it’s reputation as a city of second chances, a foodie haven, a city planning Mecca or a hiking haven was reality. So with the help of Costco Travel Services, I journeyed to the Pacific Northwest for a fact finding mission. 

After touching down at the Portland Airport, the expected nightmare of big city surface transportation began. Would it be Uber/Lyft at a cost approaching the price of the plane ticket or a New York City Taxi $80-$100 price from JFK/Newark to Manhattan? To my surprise, the trip to the inner city involved use of the ubiquitous light rail (MAX). At $1.25 for a senior citizen and $2.50 for an adult it allowed a stress free ½ hour commute close to the doorstep of our hotel in downtown Portland. The light rail went about to every important destination in the city environs. The Embassy Suites was our destination abode. Formerly, The Multnomah Hotel, it had hosted the iconic Elvis Presley, Charles Lindbergh and all presidents from Teddy Roosevelt to Richard Nixon.

The sign “Keep Portland Weird” was a few blocks from the hotel and it wasn’t long before I encountered support for its message. It was on a subsequent rail experience, an elderly male with a thinning hairline and walker entered our car clutching a flask of vodka. “I honor the Ten Commandments but I can’t love my neighbor more than myself,” he exclaimed as he swigged from his flask. A dark haired man with an earring engaged him in debate of the Ten Commandments, later joined by a guy carting a bicycle on the train who also participated. As the vodka bottle was passed around to the discussants, I realized I was witnessing a Portland exclusive.

The cuisine in downtown Portland was eclectic but stellar. As craft beer had revitalized the brewing industry, Voodoo Donuts had the imprimatur of craft donuts. I went into dessert nirvana with “Old Dirty Bastard,” a donut with fudge and peanut butter capped with an Oreo-cookie dusting. The dumplings at Afuri Ramen and Dumpling, a Tokyo based Ramen restaurant were also divine. The noodle experience was accompanied with a peak into the future because artificial intelligent iPads substituted for waiters. 

To our delight, the Trailblazers were at home hosting the San Antonio Spurs in our second day in Portland. I had always wondered why my Lakers had such a difficult time in Portland, even when they had championship caliber teams. A trip to the Moda Center provided some clues. It was a Thursday night and the place was packed. A portly fan two rows up started a “Let’s Go Blazers” chant well before the singing of the national anthem. The crowd was warmed up with a swarm of 5th graders playing rhythm xylophone followed by the governor of Oregon presenting a certificate of appreciation to the team on its 50th year anniversary. The game was close and the fans were so vocal it felt like game 7 of the NBA Finals. On our light rail trip back to the hotel, a long term fan explained the phenomena in personal terms. “I’m a recovering alcoholic, been sober for 7 years and a ticket holder that long. The basketball team is all we have.” 

As a neophyte Portland tourist, the next stop was a popular destination, the Pittock Mansion. This was an early 20th century home built by Henry Pittock, the successful editor of the Oregonian. Overlooking the Williamette River and surrounded by Oregonian Pines, it was a beacon of 20th century ingenuity and a magnificent home. While I was wandering past the fine silks, wondered how a newspaper editor could amass a fortune. I came across a clue. Henry Winslow Corbett, the senator from Oregon, had provided a cash infusion to the paper in 1872 averting bankruptcy and temporarily taking control of the city newspaper. Corbett made his initial fortune by selling farm equipment and dry goods to the farmers and families newly arrived from the Oregon Trail. When the San Francisco merchants raised their prices during the California Gold Rush, Corbett was able to undercut their prices and achieve market share. You could say he was the Pacific Northwest Walmart of the 19th century! He used the paper’s influence to back  the successful campaign of Rutherford B. Hayes, the Republican candidate for President in 1876. With political influence, both Corbett and Pittock went on to amass a fortune in banking and real estate.

The Portland experience was not complete until we took an excursion down the Columbia River Gorge. Multiple waterfalls grace the shoulders of the Columbia River Scenic Highway. We stopped at the 627 foot Multnomah Falls, the largest waterfall in Oregon. It was spotted by Lewis and Clark in 1805 and does not disappoint. Hiking was challenging during the winter due to muddy trails but swathed in a conifer blanket, the ascent was still exhilarating.

If natural beauty, great food, a workable transit system and NBA basketball is your thing, I encourage you to seek out the Portland high.