First Aid Doesn't Only Happen on White Skin
Updated: Oct 13
If our communities have many skin tones, why do so many of our training tools, examples and assumptions still start with white skin as the default?
Think about the first aid and CPR training you have completed over the years. Think about the manikins lined up on the floor. Think about the photographs in the textbook, the videos showing medical emergencies, the examples of pale skin or blue lips, the practice wounds, the bruises, the burns and the adhesive bandages pulled out of the first aid kit. Now think about how many different skin tones were represented and if they looked like your skin tone. For many people, the answer is not many and no or not so much.
This matters because real first aid is not performed on manikins. It happens on actual human beings whose bodies do not all look the same. We may be asked to recognize changes in skin color, evaluate an injury, notice bruising, identify a burn, assess circulation, respond to respiratory distress or determine whether someone's appearance has changed from their normal baseline. We may be treating a scraped knee at summer camp one day and responding to a serious medical emergency at a pool the next.
Yet our mental picture of what illness and injury "look like" is shaped by the examples we have been shown.
Medical education has been wrestling with this problem for years. A review published in the Journal of the American Academy of Dermatology described disproportionately low representation of skin of color throughout medical education and noted that widely used textbooks and educational resources have historically contained too few images showing conditions on darker skin. The authors connect that educational gap with missed or delayed diagnoses and broader health inequities.
If physicians and nurses need better education about recognizing clinical signs across skin tones, it is reasonable to ask what our first aid, CPR, lifeguard and recreation training looks like too. Our staff aren't going to provide first aid only to white people so our training shouldn't accidentally prepare them as though they will.
What We Practice Becomes Our Mental Picture of an Emergency
Training examples matter because they create reference points. If I repeatedly learn that a particular condition produces "red skin," I begin looking for red skin. If every picture of cyanosis shows obviously blue lips on a light-skinned person, that becomes my mental image of cyanosis. If every bruise in a training presentation is purple against white skin, I learn to search for that contrast. If every CPR manikin I have ever touched is white, lean and flat-chested, that becomes the body on which CPR feels familiar.
The CPR research gives us a surprisingly clear illustration of how narrow our training environments can be. A North and Latin American survey of CPR training organizations examined 2,383 manikins and found that only 12% were non-white, 6% represented women, fewer than 1% represented a non-lean body type and 1% represented pregnancy.
More recent international research doesn't suggest that the problem has disappeared. A 2025 survey included 133 organizations in 43 countries reporting on 5,364 CPR manikins. Fifty-five percent of participating organizations reported using only white, male or flat-chested, lean manikins. Only 20% used female manikins, while non-white manikins were used by about one-third of organizations.
A 2025 scoping review reached a similar conclusion. Researchers found that CPR manikins used for layperson basic life support training still do not reflect the diversity of the populations people are likely to encounter. Among educational videos reviewed in the literature, only 5% featured non-white manikins and 1% featured female manikins. The authors were careful not to claim that simply buying diverse manikins will automatically eliminate disparities in CPR outcomes, because that evidence is not established. But they did conclude that representation remains very limited and that greater diversity in simulation deserves attention.
That distinction is important. I don't think we should say that white CPR manikins cause racial disparities in emergency response. We don't have evidence to support that simple causal claim. But we absolutely can and should ask a training question: If the purpose of simulation is to prepare someone for reality, why wouldn't we want the simulation to resemble reality?
Skin Color Can Be Part of the Assessment, but Color Does Not Look the Same on Everyone
First aid courses commonly teach us to observe skin color and condition. We may be told to look for someone who becomes pale, flushed, red, blue or ashen (extremely pale or gray). Those descriptors aren't necessarily wrong, but they can become incomplete when they are taught without explaining how those changes may appear across different skin tones.
Cyanosis is a useful example. Stick with me lifeguards, cyanosis refers to discoloration associated with inadequate oxygenation. On lighter skin, learners may expect an obvious blue or purple appearance. On darker skin, that change may be less apparent on the general skin surface and may instead appear gray or white. Areas such as the lips, tongue, gums, nail beds and around the eyes can provide additional information.
Pallor presents a similar problem. Telling someone simply to "look for pale skin" assumes that the learner knows what a meaningful change looks like across skin tones. Clinical assessment guidance recommends considering areas such as the palms, conjunctiva, nail beds and inner lower lip when assessing pallor in people with darker skin.
For a recreation or day camp professional providing first aid, this does not mean trying to become a dermatologist or making a diagnosis based on someone's skin tone. It means understanding that visual signs are one piece of a larger assessment and that the textbook color word may not appear literally on every person.
Sign or injury | Common training shorthand | What responders should understand |
Cyanosis | "Blue skin or lips" | On darker skin, changes may appear gray, white or less obvious on the skin surface. Consider lips, tongue, gums, nail beds and around the eyes along with breathing, responsiveness and other signs. |
Pallor | "Pale skin" | Generalized paleness may be less obvious on darker skin. Palms, conjunctiva, nail beds and the inner lower lip may provide useful comparison points. |
Bruising | "Red, blue or purple bruise" | Bruising on darker skin may appear purple, dark brown or black and may show fewer obvious color changes during healing. Pain, tenderness and swelling matter too. |
Burns | "Red skin" | Redness may be much less obvious on darker skin. Assess the mechanism, pain, temperature, swelling, blistering, moisture, texture and other signs rather than relying only on redness. |
Inflammation | "Redness and swelling" | Redness can be subtle or difficult to see on deeply pigmented skin. Warmth, swelling, tenderness and changes from surrounding skin may be important. |
Poor perfusion | "Pale, cool skin" | Look at the whole person. Mental status, breathing, pulse, temperature, moisture and changes from their usual appearance may be more useful than searching for one expected color. |
Skin injury | "Look for discoloration" | Use more than vision. Ask about pain, feel for swelling or temperature changes when appropriate and compare with surrounding or opposite areas. |
Bruising is particularly worth discussing because it demonstrates how easy it is for a visual assessment to become unequal without anyone intentionally treating people differently.
Cleveland Clinic notes that bruises may appear purple, dark brown or black on darker skin rather than following the more familiar red-to-purple presentation often depicted on lighter skin. (Cleveland Clinic) The National Institute of Justice has also funded research into improved bruise detection because bruises can be more difficult for forensic examiners to detect on darker skin, which can affect both medical documentation and evidence following violence.
A 2026 scoping review examining bruise ascertainment among people with darker skin tones who had experienced violence reviewed 21 studies and concluded that bruises are measurably harder to detect and act upon in darker skin, with potential implications for health, protection and access to justice.
For recreation professionals, this matters in very ordinary situations too. A child falls from playground equipment. A camper says another child hit them. A basketball player collides with another player. A swimmer slips on deck. If staff have unconsciously learned that an injury should produce an obvious red or purple mark, they may place too much weight on whether they can immediately see one.
The absence of an obvious color change is not the same thing as the absence of an injury.
Burns Are Another Good Example of Why "Look for Redness" Isn't Enough
First aid training frequently uses redness as part of the description of superficial burns. Again, redness is a legitimate clinical sign. The problem is teaching it as though it will be equally visible on everyone.
Clinical burn literature has specifically noted that skin-color parameters may be less useful in people with dark skin and that other assessment characteristics may need to be considered. Even something as common as sunburn illustrates the issue: Cleveland Clinic notes that redness may be apparent on lighter skin while sunburn on darker skin can be harder to see unless peeling or blistering occurs. Pain, heat, tightness and swelling may still be present.
That suggests a very practical training change. Instead of teaching staff: "Look for red skin."
Teach: "Look for changes in color, temperature, pain, swelling, moisture, texture, blistering and the person's report of what they are experiencing."
That is better assessment for everyone.
The Best Comparison May Be the Person's Own Skin
One of the simplest changes we can make in first aid training is teaching responders to think in terms of change from baseline rather than searching for a universal color.
Instead of asking whether someone "looks pale," ask whether they look unusually pale, gray, ashen or different for them. Compare affected skin with nearby or unaffected skin when appropriate. Ask the person, caregiver or someone who knows them whether their coloring looks different from usual. Consider other signs and symptoms rather than allowing a single visual cue to determine the assessment.
This becomes particularly important when someone has deeply pigmented skin, vitiligo, albinism, scars, birthmarks, tattoos, rosacea, hyperpigmentation or other normal variation that doesn't resemble the bodies represented in a generic first aid manual.
Realistic first aid training should prepare people to assess people, not to search for the closest match to a textbook photograph.
We Also Need to Talk About the Technology in the First Aid Kit
Representation isn't only an image problem. Sometimes the tools themselves perform differently.
Pulse oximeters are a striking example. The FDA acknowledges that current scientific evidence shows differences in pulse-oximeter performance between people with lighter and darker skin pigmentation and warns that skin pigmentation is one of several factors that can affect accuracy. The agency has advised people not to rely solely on a pulse-oximeter reading and to consider symptoms and how the person is feeling as well.
In January 2025, the FDA issued draft guidance proposing stronger recommendations for testing medical pulse oximeters across a range of skin pigmentation specifically because of these concerns.
This is a fascinating first aid training lesson because it reinforces the same principle we should already be teaching: a device is information, not the person.
If a facility uses pulse oximetry within an appropriate scope of practice, staff should understand the device's limitations. A reassuring number should not override serious respiratory distress, altered mental status or other concerning symptoms. And we should be extremely cautious about turning a device reading into false certainty simply because a digital number feels more objective than human observation.
Then There Is the Humble Bandage
Not every inclusion issue in first aid is about recognizing a life-threatening emergency.
Sometimes it is a Band-Aid. For decades, products described as "flesh-colored" largely meant pink or light beige. The Science History Institute's collection documents this history and preserves examples of newer products created specifically to address it, including Tru-Colour bandages in olive, brown, dark brown and beige shades and Browndages in multiple shades of brown.
Does having a bandage that matches someone's skin tone change the medical treatment of a paper cut? No. Does it communicate something about whose body was considered the default when the product was designed? Absolutely.
Children notice these things particularly quickly. For one child, a beige bandage may disappear against their skin. For another child, the exact same product is obviously a light-colored patch sitting on their body. Neither child needs a matching bandage for wound healing, but there is no good reason our first aid kits cannot contain choices.
The solution doesn't need to be complicated. Facilities can stock transparent bandages, multiple skin-tone shades, colorful or patterned options, or the latest character du jour (Bluey, Transformers, Pokemon!). The point isn't to perfectly color-match every human being. It is to stop treating one shade as synonymous with "flesh."
This is the kind of tiny operational choice I love because it costs relatively little, requires no policy rewrite and communicates inclusion immediately.
But Representation Alone Is Not Enough
We could buy diverse manikins, stock five shades of bandages and replace every photograph in the first aid presentation and still have inequitable emergency care. Because first aid also involves judgment.
We decide whose pain seems serious. We decide who looks frightened. We decide whether a child is overreacting. We decide whether an injury "looks bad." We decide whether someone needs more help. We decide whether the person's description of what happened seems believable. Those decisions can be affected by bias.
One particularly influential 2016 study examined false beliefs about biological differences between Black and white people among white laypeople, medical students and residents.
Researchers found that false beliefs, including myths about biological differences in skin and pain sensitivity, were associated with racial bias in pain perception and treatment recommendations.
This doesn't mean every first aid responder consciously believes Black people feel less pain. It means we have substantial reason to avoid assuming that our perception of another person's pain is perfectly objective.
And the issue appears in pediatric care too. A nationally representative study of children with appendicitis found racial differences in pain treatment. Black children were significantly less likely than white children to receive opioid analgesia, including after researchers accounted for factors such as pain score.
A camp, aquatics, or recreation employee isn't prescribing pain medication, but the underlying question still matters. When two children fall on the playground and report the same amount of pain, do we respond to them with the same urgency, comfort and belief?
Adultification Bias Belongs in First Aid Training
This is where adultification bias becomes particularly important for anyone working with children. Research from Georgetown's Center for Gender Justice & Opportunity found that adults perceive Black girls as less innocent and more adult-like than white girls of the same age, with differences appearing in childhood. Black girls were perceived as needing less nurturing, protection, support and comfort and as being more independent. (CGJO)
Think about how directly those ideas could intersect with first aid.
A nine-year-old falls hard on the playground and begins crying. Does she need comforting?
A twelve-year-old tells a counselor that her ankle hurts badly. Do we believe her?
A ten-year-old becomes upset after being injured. Do we describe her as scared, or do we describe her as dramatic?
A Black girl who looks physically mature for her age gets injured at camp.
Do staff unconsciously expect her to manage the situation more independently than another child her age?
Adultification research does not specifically prove that recreation employees provide worse first aid to Black girls. We should not make that leap. What it does show is that adults can perceive Black children differently in ways that are directly relevant to how much protection, nurturing and comfort we believe they need. That is more than enough reason to put the question into our training.
A note on language: Throughout this article, I capitalize Black when referring to Black people and communities. I also use Black rather than African American when discussing research or experiences that are not specifically limited to Americans of African ancestry. The terms are not interchangeable: not every Black person is African American, and people may have individual preferences for how they identify. When referring to a specific study, I use terminology that accurately reflects the population and findings described by the researchers.
Bias or assumption | How it might show up during first aid | Better training question |
Adultification bias | Expecting a Black child to tolerate pain or manage an injury more independently | Would I offer the same comfort, caregiver support and reassurance to another child of the same age? |
Pain bias | Assuming someone is exaggerating or tolerates pain better | What is the person reporting, and what objective information do I have? |
Color-based expectation | Deciding an injury isn't serious because redness or bruising isn't obvious | What other signs are present: pain, swelling, heat, tenderness, function or change from baseline? |
White-as-default training | Looking for the exact visual presentation seen in a textbook | How might this sign appear differently across skin tones? |
Technology bias | Trusting a pulse-ox reading more than the person's symptoms | Does the device reading fit the rest of the assessment? |
Age or maturity assumption | Giving less reassurance to a child who looks older | What is this person's actual age and developmental need? |
Communication bias | Assuming someone who describes pain differently is less distressed | Have I given them an accessible way to communicate what they are experiencing? |
Behavior bias | Treating crying, withdrawal or agitation as behavior rather than distress | Could pain, fear, injury or illness be contributing to what I'm seeing? |
First Aid Training Should Include More Than Different Photographs
If we want realistic first aid training, representation has to move beyond inserting a few stock photos of people with darker skin into a PowerPoint. As we know, staff need realistic practice.
If you teach burns, show burns across different skin tones and discuss which assessment signs don't depend entirely on visible redness.
If you teach bruising, show multiple presentations and remind learners that pain and swelling can be present even when discoloration is subtle.
If you teach respiratory emergencies, discuss how cyanosis may present differently and reinforce that difficulty breathing, mental-status changes and other clinical signs matter.
If you teach shock, don't let "pale skin" become the only mental image learners have for poor perfusion.
And if you teach CPR, look at the manikins.
Who are they?
Do you have twenty identical white torsos?
Could you diversify them when equipment is replaced?
Could your training program use manikin overlays, different faces or other adaptations where appropriate?
Could training videos intentionally feature different ages, skin tones, body sizes and genders even if your physical manikin inventory cannot change immediately?
The 2025 CPR-manikin scoping review found that some organizations have already experimented with adaptations to standard manikins, including do-it-yourself approaches. Cost and availability remain legitimate barriers, which means this does not need to become an expectation that every recreation department immediately throw away perfectly functional equipment. Start with awareness. Then improve representation as equipment and materials are replaced.
Practice on the People You Actually Serve
There is a broader training philosophy underneath all of this. We should be practicing for the people who actually walk through our doors. If your recreation center serves a racially diverse community but every person represented in your emergency-response materials is white, that deserves attention. If your summer camp serves children with many different skin tones but the staff have only ever practiced assessing injuries on one another in a predominantly white staff group, that deserves attention. If your lifeguards have learned that cyanosis means "blue lips" without discussing how that sign might appear differently, that deserves attention. Not because every staff member needs to become an expert in dermatology. Because the goal of first aid training is recognition and response in the real world.
Instead of only practicing... | Add... |
"Look for redness." | Look for changes in color plus warmth, swelling, pain, tenderness, texture and function. |
"Look for pale skin." | Discuss change from baseline and assessment areas such as palms, conjunctiva and inner lips. |
"Look for blue lips." | Show examples of cyanosis across skin tones and emphasize breathing and mental status too. |
Bruises on light skin | Examples of bruising on multiple skin tones. |
Burns on light skin | Burn examples across skin tones and non-color assessment cues. |
CPR on identical white manikins | Diverse manikins or adaptations as equipment is purchased and replaced. |
An instructor describing an injury | Photographs and scenarios representing diverse people. |
Visual assessment alone | Asking the injured person what they feel and comparing with their normal baseline. |
Device numbers | Device reading plus signs, symptoms and the whole person. |
"How bad does it look?" | "What happened, what does the person report and what signs are present?" |
One generic child | Children of different races, genders, body sizes and disabilities. |
Technical first aid skills | Bias, communication, reassurance and equitable decision-making. |
There is also value in changing who plays the injured person during scenarios. If staff always practice on their closest coworker, they become familiar with one another's bodies and communication styles. Scenario-based training can deliberately vary age, skin tone, disability, body size, language, communication style and emotional response.
A scenario could involve a Black child with a possible ankle injury whose swelling is easier to identify than discoloration. Another could involve a swimmer with darker skin experiencing respiratory distress where the learner needs to assess breathing and responsiveness instead of waiting for obviously "blue" skin. Another could involve a child reporting severe pain despite little visible bruising. Another could ask staff to recognize a burn using mechanism, pain, heat, swelling and blistering rather than redness alone.
Then discuss the thinking, not simply the treatment.
Ask staff what they noticed.
Ask what they expected to see.
Ask what they couldn't see.
Ask what other information they used.
Ask whether they believed the person's report of pain.
Ask whether the person's age, race, gender, disability or communication style influenced their first impression.
Those conversations can make first aid training substantially more realistic without changing a single certification standard.
Learn From the People Already Doing This Work
There are also physicians, educators, students and creators who have spent years addressing the lack of darker skin tones in medical education. These resources can be particularly useful for first aid and recreation instructors because they provide something a written description cannot: opportunities to actually see variation. Recreation professionals should not use these resources to diagnose medical conditions outside their scope of practice, but looking at diverse clinical imagery can help instructors recognize how narrow many of our existing mental models may be.
Brown Skin Matters was created after its founders noticed how difficult it was to find examples of common skin conditions on darker skin. The project has developed a visual database showing dermatologic conditions across brown and Black skin. For first aid instructors, its value is not in teaching staff to diagnose skin disease. Its value is exposure. Looking through a resource like this makes it immediately apparent how much appearance can vary and why a single photograph in a training manual should never become our universal expectation.
Black & Brown Skin is an educational platform focused specifically on improving representation of Black and brown skin in healthcare education. It grew from the same larger problem that inspired Mind the Gap: clinical signs are often taught using language and imagery centered on white skin. The platform provides another place for instructors and professionals to explore how clinical presentation and health education can become more representative.
Skin Deep, developed by Don't Forget the Bubbles, is a free image library created to address the lack of diverse skin representation in medical education. The project includes photographs of medical conditions on different skin tones and is particularly useful because it allows educators to see the same kinds of clinical signs across a broader range of people. Although it was developed primarily for healthcare education, it is an excellent resource for anyone thinking critically about the imagery used to teach recognition.
VisualDx: Project IMPACT focuses on reducing disparities in medical education and improving representation of disease across different skin tones. VisualDx is designed primarily for healthcare professionals, so recreation staff should not treat it as a diagnostic resource. For instructors, however, Project IMPACT is useful for understanding the larger movement toward more representative medical imagery and why visual diversity is a patient-safety issue rather than simply a matter of aesthetics.
These resources are useful additions to traditional first aid materials precisely because they were created in response to a gap. We do not need lifeguards, camp counselors or recreation staff trying to become dermatologists. We do need instructors to understand that the photograph in a certification manual represents one possible presentation on one person's body. Exposure to a wider range of bodies, skin tones and clinical presentations can help us teach first aid with that reality in mind.
Audit Your First Aid Program
This doesn't need to stay theoretical. Pull out your first aid curriculum, equipment and supplies and actually look at them.
Audit area | Questions to ask |
Manikins | What skin tones, genders and body types are represented? |
Training slides | Who appears in photographs of injured and healthy people? |
Clinical examples | Are cyanosis, pallor, bruising, burns and inflammation shown across skin tones? |
Language | Do we rely heavily on color words such as red, blue and pale without explaining variation? |
First aid kits | Do adhesive bandages come in multiple skin tones, transparent options or other choices? |
Assessment | Are staff taught to use pain, warmth, swelling, texture, function and symptoms in addition to visible color? |
Devices | Do staff understand the limitations of any assessment devices they are permitted to use? |
Children | Does training address adultification and potential differences in how we perceive children's pain and vulnerability? |
Scenarios | Are people of color included in ordinary scenarios rather than only scenarios explicitly about race? |
Documentation | Do staff document what they observe rather than concluding "no injury" because discoloration is not visible? |
Purchasing | When equipment is replaced, is representation considered in procurement decisions? |
Debriefing | Do instructors ask learners what they expected to see and whether those expectations influenced their response? |
You do not need to replace everything tomorrow. But the next time you purchase manikins, you can ask different questions. The next time you revise slides, you can use different images. The next time you replenish first aid kits, you can buy different bandages. The next time you teach burns, you can stop describing redness as though it will look identical on everyone. The next time you run an in-service, you can create a scenario in which the learner has to believe someone's report of pain even when the injury isn't visually dramatic. Small changes accumulate.
First Aid Should Prepare Us for Human Beings
The problem with white-as-default first aid training isn't that every piece of traditional first aid education is wrong. Much of what we teach about emergency recognition and care remains completely applicable across skin tones. The problem is incompleteness.
"Look for redness" isn't necessarily wrong. It is incomplete.
"Look for blue lips" isn't necessarily wrong. It is incomplete.
"Look for pale skin" isn't necessarily wrong. Yup, you got it: it is incomplete.
A beige adhesive bandage works perfectly well as a medical dressing on brown skin. But calling it "flesh-colored" tells us whose flesh someone pictured when the product was designed. A white CPR manikin can teach excellent compression technique. But twenty identical white manikins tell us something about whose bodies our training environment was built around. The answer isn't to throw out everything we know about first aid. It is to make the picture bigger.
We should teach responders to recognize changes rather than memorize one color. We should teach them to assess the whole person rather than one visual sign. We should show them injuries and medical conditions across many skin tones. We should remind them that pain doesn't have to be visible to be real. We should question whether bias changes who receives comfort, reassurance or urgency. We should understand the limitations of the technology we use. We should purchase training equipment that increasingly resembles the communities we serve. And perhaps most importantly, we should stop assuming that representation in first aid is cosmetic.
When recognizing an emergency depends partly on what we see, who we practice seeing matters.
Resources & Further Reading
Dr. Malone Mukwende / Mind the Gap
Mukwende's work on clinical signs in Black and brown skin is one of the clearest examples of how representation in medical education can affect recognition. Mind the Gap was created specifically because traditional clinical education often failed to demonstrate how signs could present on darker skin.
Dr. Malone Mukwende: https://malonemukwende.com/
American Academy of Dermatology: Skin of Color
The AAD provides resources demonstrating how dermatologic conditions can present across skin tones and is a useful source for educators who want medically grounded imagery rather than relying on generic internet photographs.
Rosacea in Skin of Color: https://www.aad.org/public/diseases/rosacea/what-is/skin-color
Skin of Color Resources: https://www.aad.org/public/diseases/a-z/skin-color
Gaps in Medical Education Curricula on Skin of Color
This peer-reviewed review examines underrepresentation of skin of color in medical education and the implications for diagnosis and health equity.
Diversity of CPR Manikins for Basic Life Support Education
This 2025 scoping review examines representation of race, sex and body shape in CPR simulation and educational materials.
International CPR Manikin Diversity Survey
This 2025 research includes data from 133 organizations, 43 countries and 5,364 manikins and provides a useful snapshot of how limited representation remains in CPR simulation.
FDA: Pulse Oximeter Basics and Skin Pigmentation
The FDA explains limitations of pulse oximetry, including evidence of performance differences related to skin pigmentation, and emphasizes considering symptoms rather than relying solely on a device reading.
National Institute of Justice: Improving Bruise Detection With Alternate Light
This resource discusses challenges in detecting bruising on darker skin and research aimed at improving equitable injury documentation.
National Institute of Justice:https://nij.ojp.gov/topics/articles/improving-bruise-detection-alternate-light
Georgetown Center for Gender Justice & Opportunity: Girlhood Interrupted / Adultification Bias
Essential background on adultification bias and research finding that Black girls can be perceived as older, less innocent and needing less protection and comfort than white girls of the same age.
Georgetown Center for Gender Justice & Opportunity :https://genderjusticeandopportunity.georgetown.edu/work/initiatives/adultification-bias/
Racial Bias in Pain Assessment and Treatment Recommendations
This widely cited study examines false beliefs about biological differences between Black and white people and their relationship with racial bias in pain assessment and treatment recommendations.
PubMed Central: https://pmc.ncbi.nlm.nih.gov/articles/PMC4843483/
Racial Disparities in Pain Management of Children With Appendicitis
This JAMA Pediatrics study provides a particularly relevant example for professionals who work with children, demonstrating racial differences in pain treatment even after accounting for reported pain and other factors.
JAMA Pediatrics: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2441797
Science History Institute: Skin-Tone Bandages
The museum's digital collections document Tru-Colour and Browndages as well as the broader history of products marketed as "flesh-colored" despite representing a narrow range of skin tones.
Science History Institute: https://digital.sciencehistory.org/works/z96g3ad
The Inclusive First Aid Training Audit
One of the easiest ways to determine whether first aid training reflects the people you actually serve is to stop thinking about the program in the abstract and physically look at it. Pull out the manikins. Open the first aid kits. Scroll through the training slides. Look at the videos, scenario cards, injury photographs and assessment language. Then consider not only who is represented, but what your training is teaching staff to notice, believe and respond to.
The goal isn't to achieve a perfect score or immediately replace every piece of equipment. Some changes cost almost nothing, while others can be incorporated as equipment is replaced or training materials are updated. The more important question is whether representation and equitable assessment have ever been considered intentionally.
Audit Area | Questions to Ask | What to Look For | Possible Improvement |
CPR manikins | What skin tones do our manikins represent? | A collection of nearly identical white or light-skinned manikins | Diversify skin tones as manikins are replaced; explore available overlays or adaptations |
Manikin bodies | Do all of our manikins represent the same body? | Only lean, flat-chested adult torsos | Add variation in sex characteristics, body size, pregnancy, age and body presentation when equipment allows |
First aid photographs | Who appears in examples of injuries and medical emergencies? | Most or all examples feature light skin | Intentionally source medically accurate examples across skin tones |
Bruising examples | Do staff know what bruising can look like on different skin tones? | Training relies on obvious blue, red or purple discoloration | Show varied examples and reinforce pain, swelling and tenderness as assessment information |
Burn training | Is "redness" treated as the primary visual sign? | Learners are told simply to look for red skin | Teach pain, heat, swelling, blistering, moisture, texture and mechanism alongside color changes |
Cyanosis | Does training only describe someone as "turning blue"? | Blue lips or skin are presented as universal | Discuss how cyanosis may appear differently and reinforce assessment of breathing, responsiveness, lips, tongue, gums and nail beds |
Pallor | Does "pale" have an assumed appearance? | Only examples involving light skin | Teach change from baseline and appropriate assessment areas rather than relying on a single skin-color description |
Inflammation | Is redness treated as necessary evidence? | Staff may dismiss pain or inflammation when obvious redness is absent | Include warmth, swelling, tenderness and changes from surrounding skin |
Pain assessment | How do staff decide whether someone is in significant pain? | Heavy reliance on how distressed the person appears | Center the person's report, mechanism of injury, function and observable signs |
Children and pain | Do we discuss racial or gender bias in perceptions of children's pain? | No discussion of adultification or pain bias | Include a short scenario or discussion about equitable comfort, belief and escalation |
Comfort and reassurance | Who do staff instinctively comfort? | Older-looking or more independent children may receive less emotional support | Reinforce that reassurance and emotional care are part of first aid |
First aid bandages | What does "flesh-colored" mean in our kit? | Only light beige adhesive bandages | Stock multiple skin-tone shades, transparent options and/or colorful choices |
Training videos | Who is shown as the victim, rescuer and expert? | People of color appear rarely or only in diversity-specific material | Include diverse people throughout ordinary training examples |
Scenario cards | Do scenarios represent the actual community? | Every hypothetical victim has the same implied identity | Vary names, ages, skin tones, disabilities, genders, body sizes and family structures |
Medical devices | Do staff understand limitations of devices they use? | Device readings are treated as objective and definitive | Discuss limitations such as pulse-oximeter performance and reinforce whole-person assessment |
Communication | Can someone communicate pain without speaking? | Assessment assumes verbal communication | Include AAC, interpreters, gestures, visual scales and caregiver information where appropriate |
Disability | Are disabled people represented in ordinary first aid scenarios? | Disability only appears when disability itself is the topic | Include disabled people experiencing ordinary injuries and illnesses |
Language access | What happens when the injured person doesn't speak English fluently? | Staff depend on complex verbal questioning | Practice plain language, visual supports, interpretation resources and appropriate emergency escalation |
Documentation | How are injuries described? | "No bruising" or "no redness" becomes equivalent to "no injury" | Document observable findings, reported pain, swelling, tenderness, function and mechanism |
Incident forms | Do forms encourage objective observations? | Staff are pushed toward conclusions rather than descriptions | Use fields that capture what was observed, what the person reported and what care was provided |
Scenario realism | Do learners know the emergency before the scenario begins? | "This person has a burn. Treat them." | Give observable information and make recognition part of the exercise |
Debriefing | Do we discuss how learners interpreted what they saw? | Debriefs focus entirely on procedural steps | Ask what they expected to see, what they noticed and what influenced their decisions |
Purchasing | Is inclusion considered when equipment is replaced? | Purchasing decisions focus only on price and familiarity | Add representation and accessibility to procurement criteria |
Instructor materials | Are instructors prepared to explain differences across skin tones? | Instructor guides repeat simplistic color descriptions | Add evidence-based teaching notes and visual resources |
Community relevance | Does training resemble the people who actually use the facility? | Training demographics look nothing like the community | Compare training materials with the population your agency serves |
A Simple Way to Score It
If you want to make this part of an annual review, give each area a simple score rather than trying to create an overly complicated compliance system.
Score | Meaning |
0 — Not Addressed | We have not intentionally considered this yet. |
1 — Beginning | We recognize the issue and have made limited changes. |
2 — Incorporated | This is intentionally included in our training, materials or operations. |
3 — Embedded | This is consistently reflected in training, purchasing, scenarios, documentation and staff expectations. |
The score itself matters much less than what the conversation reveals. A facility might discover that it has excellent representation in training photographs but twenty identical CPR manikins. Another might own diverse manikins but still teach staff to look exclusively for "redness," "paleness" and "blue lips." Another might have strong clinical education but realize that every first aid scenario involves a verbal, nondisabled participant who communicates pain in exactly the way staff expect. Those aren't reasons to throw out the entire first aid program. They are opportunities to make the next version better.
If someone from our community walked into this training, would they see bodies like theirs represented not only as participants, but as people worth recognizing, believing, comforting and helping?
