Advanced Practice - Extra Cranial —
Training activity: 2

Details

Perform optimised extracranial arterial ultrasound scans to identify and grade significant extracranial disease to include:

• Minor
• Moderate
• Severe
• Occlusive

 

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
• Techniques to work around limitations common to the scanning of disease vessels in the neck
• Plaque appearance in B-mode
• Optimising the image
• The appearance of a hemodynamically significant plaque using colour Doppler
• Local SOPs
• National and international guidelines and guidance
• Cursor placements and angle correction
• Collateral pathways
• Limitations of the scan or protocol
• Scope of personal and professional practice
• Rare or incidental findings
• Artifact causes and corrections
• Referrals and escalation

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 effectively planning and preparing to undertake upper limb nerve conduction studies, specifically performing optimised extracranial arterial ultrasound scans and grading disease (minor, moderate, severe, occlusive).
• Consider how the learning outcomes apply, specifically in relation to planning and preparing and applying legislation, guidelines, and managing risk when planning and preparing for the studies, specifically assessing disease in the extracranial arteries using ultrasound and analysing and interpreting the ultrasound findings for extracranial arteries with reference haemodynamics.
• Discuss with your training officer to gain clarity of what is expected of you in relation to expectations for equipment setup, patient flow logistics, and integrating necessary safety protocols, specifically expectations for scan optimisation and disease grading.

What is your prior experience of this activity?

• Think about what you already know about planning medical procedures or preparing clinical rooms, specifically performing and optimising ultrasound scans and identifying/grading extracranial disease.
• Consider possible challenges you might face during the activity, such as logistical issues with moving NCS equipment, ensuring necessary resources (e.g., limb temperature monitors) are available, or understanding procedural requirements, specifically patient mobility, tortuosity, calcification, or other technical challenges mentioned in the indicative content.
• 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 the complexity of the planned study requires specialised equipment or protocols not covered in routine procedure, or if persistent technical issues compromise image quality for grading.
• Acknowledge how you feel about performing the specified ultrasound scans and grading disease.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as planning complex clinical procedures, specifically scan optimisation or disease grading, drawing upon previous experiences of the activity.
• Identify the specific insights you hope to gain into the detailed requirements for upper limb NCS planning, including patient flow, equipment setup, and integrating safety protocols, specifically regarding different disease severities or challenging cases.

What additional considerations do you need to make?

• Consult actions identified following previous experiences of similar planning or preparation activities, specifically performing similar scans.
• Identify important information you need to consider before embarking on the activity, such as reviewing the anatomy of upper limb nerves (median, ulnar, radial) and the procedures for motor/sensory nerve conduction studies, as this knowledge is foundational for planning, specifically anatomical variations, understanding of stroke/TIA, or current treatments.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst conducting the scan to identify and grade extracranial disease?
• Are you encountering situations such as:
  • Unexpected patient anatomy, difficult access, or unusual pathology presentation that challenge optimal grading or optimisation techniques?
  • A technical issue arises, such as severe acoustic shadowing or persistent colour gain issues, challenging your ability to obtain an optimised scan for haemodynamic grading?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding appropriately to the situation when facing an atypical disease presentation? Are you adapting or changing your approach to scanning approach or optimisation techniques to address the unexpected findings or challenges?
• Consider the steps you are taking in the moment, such as:
  • Immediately adjusting depth, frequency, or Colour Doppler settings to improve deep vessel visualisation for better B-mode assessment.
  • Performing additional views (e.g., higher neck or different angle) to confirm the presence of atypical disease.
• How are you feeling in that moment? For instance, are you finding it difficult to adapt your scanning technique to the unexpected circumstances? Is it affecting your confidence in obtaining an optimised scan and accurately grading the disease?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully achieving diagnostic quality images after technical adjustments? Or are you needing support because persistent technical difficulties or atypical disease presentation compromise the accuracy of grading?
• What are you learning as a result of the unexpected development? For example, are you mastering specific optimisation techniques for deep extracranial vessels? Or gaining insight into troubleshooting technical challenges like calcification and shadowing?

On action

What happened?

• Begin by summarising the key points of your experience performing optimised extracranial arterial ultrasound scans.
• Consider specific events, actions, or interactions which felt important, such as patient cooperation, technical difficulties (e.g., tortuosity or calcification), or unexpected findings.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately adjusting depth and frequency settings when encountering a tortuous vessel to maintain optimal B-mode 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 performing scans. What strengths did you demonstrate, e.g., in optimisation or grading? What skills and/or knowledge gaps were evident, e.g., specific disease grading (e.g., moderate vs. severe stenosis), or transducer manipulation?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in performing optimised scans?
• Identify any challenges you experienced, such as needing to seek advice or clarification regarding an unusual finding, or escalating a significant disease identification, and how you reacted to this.
• Acknowledge any changes in your own feelings now that you are looking back on the experience.

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 technique for optimising deep extracranial vessels.
• What will you do differently next time you approach an optimised extracranial arterial ultrasound scan, for instance, by proactively establishing a standardised 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 specific scan optimisation techniques or disease grading?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of performing optimised extracranial arterial ultrasound 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 patient presented with extreme vessel tortuosity forced you to re-evaluate the meticulousness of your image optimisation and velocity measurement methodology you applied during your first attempt at this training activity.
• Considering what you understand about ultrasound physics, haemodynamic grading criteria, and managing technical limitations (e.g., calcification) 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 extracranial arterial scanning technique based on further learning and experiences? For example, how you proactively implemented standardised protocols for angle correction and sample volume placement to improve the reliability of Peak Systolic Velocity (PSV) readings, demonstrating you have adapted improvements based on further learning.
• Has discussing technically challenging scans or the impact of inaccurate grading on patient management decisions with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a misclassified moderate stenosis refined your understanding of the critical nature of meticulous technique and application of grading criteria.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent extracranial arterial ultrasound scanning experiences, contributed to your overall confidence and competence in performing optimised scans and grading significant extracranial disease, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in rapid image optimisation now enables you to confidently achieve diagnostic quality images and correctly grade stenosis severity 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 optimised extracranial arterial ultrasound 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 persistent, severe acoustic shadowing obscures the residual lumen at the site of maximal stenosis, recognising this falls outside routine troubleshooting scope.
• Looking holistically at your training journey, how has this initial extracranial arterial ultrasound scanning experience, revisited with your current perspective, contributed to your development in meeting the objectives related to assessing disease and applying ultrasound physics? For example, how this foundational experience has supported your development in systematic grading of stenosis.

Relevant learning outcomes

#	Outcome
# 2	Outcome Assess disease in the extracranial arteries using ultrasound.
# 3	Outcome Apply ultrasound physics to correctly optimise an ultrasound scan.
# 4	Outcome Analyse and interpret the ultrasound findings for extracranial arteries with reference haemodynamics.
# 7	Outcome Appraise the impact of research evidence on national guidelines.
# 8	Outcome Critically evaluate the clinical significance of incidental findings.
# 9	Outcome Summarise surgical and endovascular interventions performed for carotid disease.