Advanced Practice - Arterial —
Training activity: 2

Details

Perform optimised ultrasound scans following a set protocol to identify normal lower limb arterial anatomy (Aorta to ankle)

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

• Patient centred care and support
• Normal anatomy and anatomical variations on ultrasound
• Equipment selection
• Scanning techniques
• Control optimisation in B-mode, colour Doppler and spectral Doppler
• Haemodynamics and physiology
• Local SOPs
• Local and national guidelines
• Artifact causes and corrections
• Limitations of the scan
• Scope of personal and professional practice
• Consequences of misdiagnosis
• Patient safety and communication

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 successfully perform optimised ultrasound scans and assess disease in the lower limb arteries from the aorta to the ankle.
• Consider how the learning outcomes apply, specifically in relation to applying ultrasound physics to correctly optimise the scan.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the precise scan protocol for normal anatomy, expected image quality parameters, and typical normal appearances (e.g., spectral waveforms, vessel dimensions).

What is your prior experience of this activity?

• Think about what you already know about vascular anatomy and normal haemodynamics.
• Consider possible challenges you might face during the activity, such as patient positioning, deep or small vessels, or ensuring comprehensive coverage.
• 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 if you need guidance on optimisation, identifying anatomy, or troubleshooting technical challenges.
• Acknowledge how you feel about performing a complete, optimised scan of normal lower limb arterial anatomy.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as probe manipulation, image optimisation techniques (B mode, Colour Doppler, Spectral Doppler).
• Identify the specific insights you hope to gain into establishing a consistent and efficient scanning workflow for comprehensive lower limb arterial assessment.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of prior scanning experiences.
• Identify important information you need to consider before embarking on the activity, such as detailed anatomical diagrams, or specific equipment settings for optimising arterial flow studies.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst performing optimised ultrasound scans for normal lower limb arterial anatomy?
• Are you encountering situations such as:
  • Unexpected anatomical variations (e.g., highly complex deep calf vessel branching) that challenge the standard scan protocol?
  • Persistent poor image quality or difficult access due to patient body habitus, complicating the clear identification of normal vessel wall characteristics or expected waveforms?

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 probe manipulation, depth, or frequency to improve visualisation?
• Consider the steps you are taking in the moment, such as:
  • Immediately adjusting the Colour Doppler PRF and gain settings to accurately define the flow boundaries in a suspected small calf vessel
  • Pausing the scan to reposition the patient or use a non-standard acoustic window (e.g., lateral approach) to bypass superficial impediments and visualise deep segments
• How are you feeling in that moment? For instance, are you finding it difficult to maintain composure when facing unexpected anatomical complexity? Is it affecting your confidence in comprehensively identifying all normal anatomy?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully employing specific image optimisation techniques (e.g., reducing depth, adjusting frequency) to ensure clear identification of the normal arteries? Or are you needing support because poor image quality prevents comprehensive assessment of a deep arterial segment, requiring confirmation from a senior colleague?
• What are you learning as a result of the unexpected development? For example, are you mastering a more efficient technique for deep vessel visualisation? Or gaining insight into the critical optimisation settings required for evaluating normal arterial haemodynamics?

On action

What happened?

• Begin by summarising the key steps you took when performing the ultrasound scan to identify normal lower limb arterial anatomy.
• Consider specific events, actions, or interactions which felt important, such as how you applied the principles of ultrasound physics to correctly optimise the scan or how you ensured comprehensive coverage of the aorta to ankle protocol.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded to correctly optimise the scan or identify normal anatomy, for instance, immediately adjusting the depth and frequency settings when encountering a deep segment to maintain optimal image quality.
• How did you feel during this experience, e.g., did you feel focused on achieving optimal image quality or frustrated by persistent technical issues?

How has this experience contributed to your developing practice?

• Identify what learning you can take from the experience of scanning normal lower limb arterial anatomy. What strengths did you demonstrate, e.g., technical precision in probe manipulation or the ability to accurately correlate B-mode appearance with expected normal haemodynamics?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the specific settings required for optimising flow in smaller, distal vessels?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development in scan optimisation achieved? Has your practice improved in identifying normal arterial anatomy?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding unexpected anatomical variations or persistent technical challenges that compromised image quality, 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 your consistent application of ultrasound physics principles to optimise scans.
• What will you do differently next time you approach an ultrasound scan for normal anatomy, for instance, by proactively establishing a standardized sequence for adjusting gain, frequency, and depth settings before starting the examination?
• Do you need to practise any aspect of the activity further, such as refining your technique for deep vessel visualisation 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 performing optimised scans for normal lower limb arterial anatomy since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how an instance where a subsequent scan required highly sensitive Doppler settings to clearly delineate normal triphasic flow in a deep vessel forced you to re-evaluate the thoroughness of your initial optimisation settings you applied during your first attempt at this training activity.
• Considering what you understand about ultrasound physics, spectral waveform characteristics, and vessel anatomy 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 scan optimisation technique for normal anatomy based on further learning and experiences? For example, how you proactively integrated a standardized checklist for assessing B-mode, Colour, and Spectral Doppler parameters to consistently achieve optimal image quality.
• Has discussing challenges in visualising deep or tortuous normal vessels or the impact of sub-optimal image quality on haemodynamic assessment with peers or colleagues changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a time when poor optimisation led to misinterpretation of normal flow patterns refined your understanding of the critical nature of meticulous image optimisation.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent normal anatomy scanning experiences, contributed to your overall confidence and competence in optimising ultrasound scans to identify normal lower limb arterial anatomy, particularly in preparing for assessments like DOPS or OCEs? For example, how your accumulated ability in accurately identifying and documenting normal vascular anatomy now enables you to confidently perform and interpret a normal peripheral arterial scan during a DOPS assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to optimising ultrasound scans for normal lower limb arterial anatomy? 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 readily recognise when a scan is not achieving optimal views and routinely seek assistance to ensure reliable demonstration of applying the principles of ultrasound physics to adjust and optimise an ultrasound machine to obtain quality images.
• Looking holistically at your training journey, how has this initial normal lower limb arterial anatomy scanning experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to assessing vascular anatomy using ultrasound and applying the principles of ultrasound physics to correctly optimise the scan? For example, how this foundational experience has supported your development in meeting the learning outcome related to applying the principles of ultrasound physics to adjust and optimise an ultrasound machine to obtain quality images.

Relevant learning outcomes

#	Outcome
# 2	Outcome Assess disease in the lower limb arteries using ultrasound.
# 4	Outcome Apply ultrasound physics to correctly optimise an ultrasound scan of the lower limb arteries.
# 9	Outcome Appraise the impact of research evidence on national guidelines.