Training activity information
Details
Perform optimised ultrasound scans to identify a below knee DVT
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
- Local SOPs
- National guidance
- Clinical presentation of acute and chronic DVT
- Image optimisation
- Appearance of acute and chronic thrombus on ultrasound
- Limitations of the scan
- Unusual pathology and differential diagnoses
- Acting on urgent findings
- Scope of personal and professional practice
- Patient safety and communication
- Artifact causes and corrections
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 performing an optimised ultrasound scan to identify a below knee DVT.
- Consider how the learning outcomes apply, specifically in relation to assessing lower limb venous thrombosis and optimising the scan for small calf vessels.
- Discuss with your training officer to gain clarity of what is expected of you in relation to expected technical and diagnostic standards for calf veins, including systematic compression and differentiation of the soleal and gastrocnemius veins.
What is your prior experience of this activity?
- Think about what you already know about calf venous anatomy, DVT presentation, and scanning protocols for below knee DVT.
- Consider possible challenges you might face during the activity, such as small vessel size, patient discomfort during calf compression, or distinguishing subtle thrombus from reverberation artefact.
- 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 indeterminate findings persist or if you suspect calf muscle pathology (e.g., Baker’s cyst, haematoma).
- Acknowledge how you feel about embarking on this ultrasound scanning activity, particularly the technical difficulty of calf veins.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as precise transducer control and systematic compression technique in the calf, and optimising Doppler for small vessel flow.
- Identify the specific insights you hope to gain into the technical nuances of below knee DVT assessment and the differential diagnosis for calf pain.
What additional considerations do you need to make?
- Consult actions identified following previous experiences of ultrasound scanning (e.g., improving patient cooperation or managing artefacts).
- Identify important information you need to consider before embarking on the activity, such as patient history, specific symptoms related to calf pain, and the protocol recommendations for calf vein assessment.
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst performing optimised ultrasound scans to identify a below knee DVT?
- Are you encountering situations such as:
- Extreme small vessel size or deep positioning of calf veins (e.g., peroneal veins), complicating systematic compression?
- Patient experiences unexpected severe discomfort during calf compression, threatening cooperation and measurement fidelity?
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 frequency or compression pressure?
- Consider the steps you are taking in the moment, such as:
- Immediately switching to a high-frequency probe or applying minimal B-mode compression technique for small calf vessels
- Pausing the scan to reassure the patient and adjust compression pressure or technique to improve cooperation
- How are you feeling in that moment? For instance, are you finding it difficult to maintain precise transducer control? Is it affecting your confidence in comprehensively assessing all distal deep veins?
What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully completing systematic compression despite initial technical difficulty? Or are you needing support because indeterminate findings persist in a small vessel or if suspicion of calf muscle pathology (e.g., Baker’s cyst) is encountered?
- What are you learning as a result of the unexpected development? For example, are you mastering precise calf vein compression techniques? Or gaining insight into the technical difficulty of imaging below knee DVT?
On action
What happened?
- Begin by summarising the key steps you took when performing the ultrasound scan to identify a below knee DVT, including the specific anatomical areas scanned and any challenges encountered in the calf.
- Consider specific events, actions, or interactions which felt important, such as patient discomfort during calf compression, difficult imaging windows, or subtle findings (e.g., non-occlusive thrombus), and your own feelings.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately switching to a high-frequency probe or adjusting compression technique when struggling to visualise distal calf veins.
- How did you feel during this experience, e.g., did you feel challenged by the technical demands of calf vessel imaging or focused on achieving comprehensive assessment?
How has this experience contributed to your developing practice?
- Identify what learning you can take from performing this scan. What strengths did you demonstrate, e.g., precise transducer control or systematic application of compression techniques for complex anatomy?
- What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the typical appearance of specific calf perforators or difficulty optimising Doppler settings for low flow states?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in navigating complex anatomy for below knee DVT identification?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding an indeterminate finding in a small calf vessel or escalating a finding, 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 the technical efficiency and systematic coverage of calf vessels.
- What will you do differently next time you approach an ultrasound scan for a below knee DVT, for instance, by proactively reviewing anatomical variations of calf veins before starting the scan on a difficult patient.
- Do you need to practise any aspect of the activity further, such as refining compression technique for calf veins or key learning outcomes related to optimisation for small vessels?
Beyond action
Have you revisited the experiences?
- How have your subsequent experiences of performing below knee DVT scans 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 meticulous small vessel imaging to identify a subtle thrombus in a peroneal vein forced you to re-evaluate the rigidity of your initial approach to calf vein assessment you applied during your first attempt at this training activity.
- Considering what you understand about calf vein anatomy, systematic compression, and small vessel optimisation 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 below knee DVT scanning technique based on further learning and experiences? For example, how you proactively integrated specific high-frequency probe settings and systematic segmental compression to ensure coverage of all deep calf veins, demonstrating you have adapted improvements based on further learning.
- Has discussing challenges in visualising deep calf vessels or the impact of patient discomfort during calf compression 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 case where an unidentified below knee DVT led to complications refined your understanding of the critical nature of comprehensive and precise calf vein assessment.
How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent below knee DVT scanning experiences, contributed to your overall confidence and competence in performing optimised ultrasound scans to identify venous thrombosis, particularly in preparing for assessments like DOPS? For example, how your accumulated ability in systematic calf assessment now enables you to confidently perform full ultrasound assessment of the deep leg veins including calf veins, gastrocnemius and soleal veins 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 performing below knee DVT scans? 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 faced with a complex differential diagnosis in the calf (e.g., muscle tear vs. atypical DVT) that requires senior interpretive input.
- Looking holistically at your training journey, how has this initial below knee DVT scanning experience, revisited with your current perspective, contributed to your development in meeting the objectives related to assessing lower limb venous thrombosis? For example, how this foundational experience has supported your development in applying ultrasound physics for correct optimisation.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 2 |
Outcome
Assess lower limb venous thrombosis using ultrasound. |
| # 4 |
Outcome
Apply ultrasound physics to correctly optimise an ultrasound scan of the lower limb veins. |
| # 9 |
Outcome
Appraise the impact of research evidence on national guidelines. |