Training activity information
Details
Perform extracranial carotid ultrasound scans and assess the plaque morphology, grading a range of plaque types
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
- Describing plaque morphology
- Limitations of the scan or protocol
- Identification of “vulnerable plaque”
- Identification of ulcerated plaques
- Scope of personal and professional practice
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 carotid ultrasound scans and assessing/grading plaque morphology.
- 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.
- 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 plaque assessment.
What is your prior experience of this activity?
- Think about what you already know about planning medical procedures or preparing clinical rooms, specifically performing carotid scans and assessing plaque morphology.
- 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 highly calcified plaques, tortuous vessels affecting imaging.
- 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 unusual or high-risk plaque features are identified that require immediate clinical input.
- Acknowledge how you feel about performing the ultrasound scans and making an accurate assessment based on these.
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 plaque characterisation and 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 plaque characterisation and IMT.
What additional considerations do you need to make?
- Consult actions identified following previous experiences of similar planning or preparation activities, specifically scanning carotids or assessing plaque.
- Identify important information you need to consider before embarking on the activity, such as reviewing 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 understanding of plaque characterisation and IMT.
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst scanning and assessing plaque morphology?
- Are you encountering situations such as:
- Unusually complex plaques, severe calcification causing shadowing, or difficulty visualising the plaque due to anatomical constraints?
- Identifying a high-risk plaque feature (e.g., ulceration or intraplaque haemorrhage) that requires immediate, precise documentation and clinical urgency assessment?
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding appropriately to the situation when an unexpected plaque morphology was encountered? Did you adapt or change your scanning technique or image optimisation to better assess the challenging plaque?
- Consider the steps you are taking in the moment, such as:
- Immediately adjusting the image settings (e.g., increasing frequency) to enhance B-mode definition for detailed plaque characterisation.
- Using multiple transducer angles to minimise acoustic shadowing and confirm plaque margins for accurate grading.
- How are you feeling in that moment? For instance, are you finding it difficult to adapt your approach to accurately visualise and grade the plaque? Is it affecting your confidence in comprehensively assessing the plaque morphology?
What is the conclusion or outcome?
- Identify how you worked within your scope of practice. For example, are you successfully documenting and grading the plaque morphology (e.g., homogenous vs. heterogeneous)? Or are you needing support because the plaque exhibits unusual features requiring specialist verification?
- What are you learning as a result of the unexpected development? For example, are you mastering specific image optimisation for plaque assessment? Or gaining insight into the technical limitations imposed by calcification?
On action
What happened?
- Begin by summarising the key points of your experience performing carotid ultrasound scans and assessing plaque morphology.
- Consider specific events, actions, or interactions which felt important, such as how you measured the degree of stenosis, how you managed acoustic shadowing, or how you characterised the plaque.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately adjusting the B-mode focus and frequency settings to enhance visualisation of a suspected ulceration, adapting the scanning technique based on plaque characteristics.
- How did you feel during this experience, e.g., did you feel focused on differentiating between the pathologies or stressed by the diagnostic uncertainty caused by technical challenges?
How has this experience contributed to your developing practice?
- Identify what learning you can take from the experience. What strengths did you demonstrate, e.g., in visualising or grading different plaque types?
- What skills and/or knowledge gaps were evident, e.g., specific morphology identification (e.g., heterogeneity), challenging calcifications?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in assessing plaque morphology?
- Identify any challenges you experienced, such as needing to seek advice or clarification on a complex plaque, or escalating an unstable plaque finding, 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 meticulous B-mode assessment for high-risk plaques.
- What will you do differently next time you approach a carotid ultrasound scan to assess plaque morphology, for instance, by proactively reviewing academic content related to the relationship between plaque morphology (e.g., lipid core) and embolic risk?
- Do you need to practise any aspect of the activity further, such as assessing challenging plaque morphologies?
Beyond action
Have you revisited the experiences?
- How have your subsequent experiences of assessing plaque morphology 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 precise B-mode characterisation of a highly heterogeneous plaque with suspected ulceration forced you to re-evaluate the initial quick assessment methodology you applied during your first attempt at grading plaque types.
- Considering what you understand about plaque stability indicators, morphology grading criteria, and the use of IMT 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 plaque assessment technique based on further learning and experiences? For example, how you proactively implemented the use of specific high-resolution imaging settings to better visualise plaque surface irregularity to improve ulceration detection, demonstrating you have adapted improvements based on further learning.
- Has discussing high-risk plaque findings or the impact of inaccurate morphology grading on surgical/endovascular intervention 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 case where a severe but stable plaque was over-reported refined your understanding of the critical nature of objective plaque characterisation.
How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent plaque assessment experiences, contributed to your overall confidence and competence in performing carotid ultrasound scans and assessing plaque morphology, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS)? For example, how your accumulated ability in assessing plaque stability now enables you to confidently apply B-mode criteria to grade plaque type 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 extracranial carotid ultrasound scans and assessing plaque morphology? 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 a plaque exhibits high-risk features suggestive of dissection or haemorrhage that require immediate escalation protocols.
- Looking holistically at your training journey, how has this initial plaque assessment experience, revisited with your current perspective, contributed to your development in meeting the objectives related to assessing disease? For example, how this foundational experience has supported your development in appraising the impact of research evidence on national guidelines.
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. |
| # 7 |
Outcome
Appraise the impact of research evidence on national guidelines. |