Don't agree with SpO
2
Even dedicated pulse oximeters can be tricked if hand is too cold or sweaty.
SpO2 is not a even direct measurement, it is just an estimation, and I was saying that smartwatches have gotten pretty good at estimating it, and dedicated pulse ox are even better but both cannot be fully relied upon as they have their limitations, sometimes very big limitations.
As you have said, they can be tricked when hands are cold (because peripheral vasoconstricion happens due to hyothermia and that reduces the amount of blood reaching the finger), nail paint application prevents enough light to pass thought the finger affecting the measurement (in transmissive pulse ox), hypotension or low cardiac output can cause reduced peripheral perfusion, patients who are smokers have high spo2 reading because of increased carbon monooxide in their blood, pairtents with very dark skin have increased reading with reflective pulse ox, improper use can cause false readings (patients tend to clamp it tightly on their fingers to get more accurate reading but that occludes the vessels, hence affecting the reading, sweaty fnigers, hairy arm (in reflectance based pulse ox), improper use (moving too much/improper contact between sensor and skin) cause motion artefacts which are more common in reflective type pulse ox, there are so many other limitations that aren't coming to my mind right now. Whenever there is an actual doubt regarding hypoxemia, an arterial blood gas analysis is done to be sure, but that is an invasive procedure and has its own limitations.
I'm not disagreeing, all I'm saying is a pulse ox (weather reflective or transmittive) does an estimation and can never report absolute value but they have gotten pretty good (transmittance once) that they are commonly accepted in clinics even though they never report absolute value and have so many limitations.
Everything has pros and cons, Pulse Ox is non-invasive, quick, cheap, no setup required, does not require any cost per test, does not require much skill to use, no complications, etc. On the other hand ABG gives almost absolute value but it is invasive process, requires much skill to draw arterial blood, has associated complications, requires costly machine, per test cost is there (kit cost), etc. Pulse Ox are approx 95% accurate so we trade the 5% inaccuracy with the added benefits of pulse ox.
Smart watche SpO2 are less accurate than transmittance based pulseox, so lets say they are 90% accurate (just an estimation, maybe they are 85% accurate, maybe 92% accurate) still they are not going to report a 85% on RA patient to be 97%. This is what I was trying to say. Any indirect measurement should never be relied upon when there is a medical doubt / impending emergency, that's why there are other higher testing methods. But SpO2 indirect measurements have gotten considerably good that it will, almost in all the cases, report something before there is anything serious or before some medical intervention is required.
Similarly, we should try to get direct measurements wherever possible, like heart rate can be very easily measured by counting pulse for 60 seconds. It will surely differenciate between 90bpm vs 150bmp. Critical values should always be double checked. Smart watches have their limitations and should not be relied upon in critical / medical cased but they are def more than just toys. Apple watch can even get ECG (although just one lead (only lead 1), in hospitals 12 lead ECG is done) but that lead-1 ECG is combined with multiple other factors to enhance its accuracy and it can very well measure the actual electrical activity of heart and tell about A. Fib or some other irregular rhythms and alert the wearer to go to clinic or something.