Advanced Practice - Arterial —
Training activity: 10

Details

Identify and minimise artefacts caused by pathology during  ultrasound scans of the lower limb arteries using:

• B mode
• Colour Doppler
• Spectral Doppler

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Artefact causes e.g. calcification, aliasing
• Imaging controls and optimisation
• Quality assurance
• Pathophysiology
• Ultrasound physics

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to identifying artefacts caused by pathology and apply appropriate optimisation techniques to minimise their impact on image quality and interpretation.
• Consider how the learning outcomes apply, specifically in relation to applying appropriate optimisation techniques.
• Discuss with your training officer to gain clarity of what is expected of you in relation to common artefacts encountered in vascular ultrasound, specific optimisation strategies for each, and how to differentiate artefacts from true pathology.

What is your prior experience of this activity?

• Think about what you already know about the physical principles behind different types of artefacts and how they can obscure pathology.
• Consider possible challenges you might face during the activity, such as significant pathology creates challenging artefacts, or when attempting to visualise distal to an occluding lesion with heavy calcification.
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example on a particularly challenging artefact situation or when you are unsure if a finding is artefact or true pathology.
• Acknowledge how you feel about proactively identifying and managing artefacts during your scans.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as deepening your understanding of ultrasound physics, improving problem-solving skills during scanning and ability to obtain diagnostic images despite technical challenges.
• Identify the specific insights you hope to gain into how effective artefact minimisation contributes to diagnostic accuracy.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of where image quality was compromised by artefacts.
• Identify important information you need to consider before embarking on the activity, such as relevant sections of ultrasound physics related to artefact generation and control.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst identifying and minimising artefacts caused by pathology?
• Are you encountering situations such as:
  • Severe, persistent Colour Doppler aliasing occurs that cannot be resolved by routine adjustments of the PRF scale, suggesting a critical high-velocity jet is being underestimated?
  • Reverberation or side-lobe artefacts mimic anatomical structures or obscure flow information distal to a lesion, compromising diagnostic accuracy?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to adjusting the machine filters, spatial compounding, or probe position to mitigate the artefact?
• Consider the steps you are taking in the moment, such as:
  • Immediately adjusting the B-mode focus position or transducer frequency to minimise shadowing or lateral artefact caused by calcification
  • Actively changing the angle of insonation and the wall filter setting to eliminate persistent noise or colour bleed without compromising true signal detection
• How are you feeling in that moment? For instance, are you finding it difficult to maintain patience when facing persistent technical interference? Is it affecting your confidence in obtaining a diagnostically reliable image?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully applying your knowledge of ultrasound physics to eliminate or minimise the artefact through technical adjustments? Or are you needing support because the technical issue persists, requiring senior technical staff or suggesting the necessity of recommending an alternative imaging modality?
• What are you learning as a result of the unexpected development? For example, are you mastering a more effective sequence of steps for troubleshooting colour Doppler artefacts? Or gaining insight into how specific pathological characteristics (e.g., severe calcification) fundamentally limit image acquisition?

On action

What happened?

• Begin by summarising the key points of your experience identifying and minimising artefacts caused by pathology during ultrasound scans of the lower limb arteries.
• Consider specific events, actions, or interactions which felt important, such as how you applied the principles of ultrasound physics to correctly identify the source of the artefact (e.g., reverberation, shadowing) or the technical steps taken to mitigate persistent noise.
• Include any ‘reflect-in-action’ moments where you had to adapt your technique or settings to address artefacts, for instance, immediately adjusting the wall filter and PRF when aliasing complicated the assessment of a high-velocity jet.
• How did you feel during this experience, e.g., did you feel focused on technical problem-solving or frustrated by the persistent image corruption?

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience of managing artefacts. What strengths did you demonstrate, e.g., systematic troubleshooting of technical parameters or the ability to apply physics knowledge to mitigate shadowing?
• What skills and/or knowledge gaps were evident, e.g., uncertainty regarding the specific filters required to eliminate low-frequency noise in Colour Doppler or difficulty distinguishing a severe artefact from an unusual pathological finding?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development in artefact identification and minimisation achieved? Has your practice improved in producing artefact-free images?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding persistent, unresolvable technical issues that compromised diagnostic quality, requiring senior technical input, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving technical troubleshooting and artefact mitigation strategies.
• What will you do differently next time you approach an ultrasound scan and encounter artefacts, for instance, by proactively reviewing the academic content on Image optimisation and Imaging artefacts to anticipate specific technical challenges based on the patient’s history?
• Do you need to practise any aspect of the activity further, such as refining the use of spatial compounding to reduce shadowing or key learning outcomes related to applying ultrasound physics to correctly optimise the scan?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of identifying and minimising artefacts caused by pathology since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where persistent Colour Doppler aliasing required immediate, complex PRF and gain adjustments forced you to re-evaluate the foundational physics knowledge and troubleshooting sequence you applied during your first attempt at artefact management.
• Considering what you understand about ultrasound physics, artefact generation (e.g., shadowing, aliasing, reverberation), and technical troubleshooting now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your artefact management protocols based on further learning and experiences? For example, how you proactively reviewed and integrated the academic content on Image optimisation and Imaging artefacts to anticipate specific technical challenges.
• Has discussing challenging artefact situations (e.g., distinguishing complex pathology from side-lobe artifacts) with peers or experienced colleagues changed how you now view your initial experience in this training activity? For example, how professional storytelling with a technical specialist about an inconclusive scan report due to persistent technical interference refined your understanding of the critical nature of vigilant artefact mitigation.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent artefact management experiences, contributed to your overall confidence and competence in identifying and minimising artefacts caused by pathology, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in technical troubleshooting now enables you to confidently apply the principles of ultrasound physics to adjust and optimise the scan during a practical assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to identifying and minimising artefacts? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice immediately when an artefact is too significant to overcome within your scope of practice (e.g., severe bowel gas obscuring the aorta), recognising this requires senior input for applying the principles of ultrasound physics to correctly optimise the scan.
• Looking holistically at your training journey, how has this initial artefact management experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to applying the principles of ultrasound physics to correctly optimise the scan? For example, how this foundational experience has supported your development in refining your ability to obtain diagnostic images despite technical challenges.

Relevant learning outcomes

#	Outcome
# 4	Outcome Apply ultrasound physics to correctly optimise an ultrasound scan of the lower limb arteries.