In EMS, traditionally, the phrase “pink, warm and dry” is an easily remembered shortcut to indicate a healthy skin assessment. It is a clue that the patient’s circulation, oxygenation, and metabolic status are probably normal. The opposite of this is “pale, cool and clammy.”
Using pink to define normal can lead to some confusion in the training of EMS providers and underrecognition of serious illness in people of color. This bias may be contributing to the known health inequalities linked to ethnicity.
Think of something pink, like a pink flamingo or the flesh of a salmon. Do people actually look that color? I have never seen a pink person. I can tell you as an artist that if I just used pink to paint a portrait, it would not be very realistic at all. Skin tone is a combination of colors that arises from pigmentation. There are five factors that determine skin color:
Hemoglobin and blood flow. Oxygenated hemoglobin absorbs and reflects light differently from deoxygenated hemoglobin, contributing to differences in the appearance of blood-rich tissues. Vasodilation increases blood flow and therefore redness, whereas vasoconstriction decreases blood flow, making the skin paler. Venous congestion can result in a dusky or purple color.
Carotenoids are yellow-orange pigments from beta-carotene in diets. (Caucasian babies fed too much carrot baby food can appear yellow. This is in contrast to jaundice which also affects the sclera of the eyes.)
Skin thickness can affect light scattering from the different layers of the skin. Consider the difference in color between mucosa, lips, and face.
Environmental and physiological influences such as ultraviolet exposure, hormones, temperature, inflammation, injury, and aging, just to name a few.
Melanin is a pigment produced by cells called melanocytes in the basal skin layer. People of different skin tones generally have similar numbers of melanocytes. The differences are primarily in how pigment is produced and distributed. But the increased presence of melanin significantly changes how oxygenation, perfusion, congestion and bruising appear. Brown skin tends to be more yellow in shock; whereas black skin tends to be more grey in shock, but you will have to look at the tongue, mucosa, palms, or nail beds to see changes. In pigmented individuals, the tongue is the best place to look for cyanosis. Also inner lips or gums may reveal changes better than external skin.
The description of skin as pink was inherited by EMS in the 1960s from Western European physicians and nurses who historically used this terminology in bedside assessment in the evaluation of predominantly caucasian patients. Even though pink seems like a good simple choice to describe well-perfused skin, it is not very accurate.
We would be better off using the term “normal” (as in normal for that individual). Gradually, the term pink will be replaced with the term normal in EMS terminology to more accurately document assessment of all skin tones.
References:
1. Harrison, J. (2023) ‘A scoping review exploring the confidence of healthcare professionals in assessing all skin tones’, British Paramedic Journal, 8(2), pp. 18–28. Available at: https://doi.org/10.29045/14784726.2023.9.8.2.18
2. Harrison, J. (2025) ‘Paramedic education: Are we teaching an inclusive clinical assessment approach that is effective for patients of all skin tones?’, Paramedicine, 22(6), pp. 285–290. Available at: https://doi.org/10.1177/27536386251335652
3. Padgett, J.S. and Hawkins, S.C. (2026) ‘Skin color assessment in EMS education and practice’, EMS World, 5 January. Available at: https://www.hmpgloballearningnetwork.com/site/emsworld/feature/skin-color-assessment-ems-education-and-practice
