Training activity information
Details
Review and report ultrasound finding with subclavian steal phenomenon
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
- Subclavian artery origin
- Vertebral artery for retrograde flow
- Comparison of bilateral brachial pressure
- Limitations of the scan or protocol
- Communication skills
- Acting on urgent findings
- Patient pathways
- Multidisciplinary team working
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 reviewing and reporting ultrasound findings related to subclavian steal phenomenon.
- 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 analysing and interpreting the ultrasound findings for extracranial arteries with reference haemodynamics, and applying ultrasound physics to correctly optimise an ultrasound scan.
- 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 identifying and reporting this specific phenomenon.
What is your prior experience of this activity?
- Think about what you already know about planning medical procedures or preparing clinical rooms, specifically subclavian steal phenomenon and its ultrasound presentation.
- 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 in identifying or reporting this condition.
- 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 the findings are atypical or suggest a complex multi-level lesion.
- Acknowledge how you feel about undertaking the review and reporting of ultrasound finding in the context of this training activity.
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 recognising and interpreting subclavian steal phenomenon, 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 the specific characteristics of subclavian steal on ultrasound.
What additional considerations do you need to make?
- Consult actions identified following previous experiences of similar planning or preparation activities, specifically reviewing or reporting unusual findings.
- 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 the specific characteristics of subclavian steal on ultrasound.
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst reviewing and reporting on a subclavian steal phenomenon?
- Are you encountering situations such as:
- Ambiguous spectral Doppler waveforms (e.g., early systolic reversal only) or unusual collateral flow patterns that complicate classification of the degree of steal?
- The patient’s clinical presentation (e.g., asymptomatic) not fully aligning with the haemodynamic findings of complete subclavian steal?
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding appropriately to the situation when the presentation of subclavian steal was atypical? Did you adapt or change your review methodology or reporting style to accurately capture the phenomenon?
- Consider the steps you are taking in the moment, such as:
- Immediately re-evaluating the vertebral artery waveform post-arm exercise to confirm the flow direction and classify the stage of the steal.
- Consulting reference literature to confirm the criteria for differentiating partial vs. complete steal before drafting the report.
- How are you feeling in that moment? For instance, are you finding it difficult to adapt your interpretation to the nuances of the subclavian steal phenomenon? Is it affecting your confidence in correctly identifying and reporting the findings?
What is the conclusion or outcome?
- Identify how you worked within your scope of practice. For example, are you successfully confirming the diagnosis of subclavian steal using haemodynamic assessment? Or are you needing support because the findings are highly equivocal, requiring a second opinion or additional diagnostic review to confirm the findings?
- What are you learning as a result of the unexpected development? For example, are you mastering the technique for evaluating flow reversal and differentiating it from artifact? Or gaining insight into the role of haemodynamics in diagnosing proximal arch disease?
On action
What happened?
- Begin by summarising the key points of your experience reviewing and reporting the subclavian steal phenomenon.
- Consider specific events, actions, or interactions which felt important, such as quantifying the degree of steal, correlating findings with patient symptoms, or discussions with colleagues.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately confirming the diagnosis by performing arm exercise and re-recording the vertebral artery waveform when the initial finding was borderline or partial steal.
- How did you feel during this experience, e.g., did you feel confident in recognising or challenged in quantifying the steal?
How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience. What strengths did you demonstrate, e.g., in identifying and reporting subclavian steal?
- What skills and/or knowledge gaps were evident, e.g., differentiating partial vs. complete steal, or understanding clinical significance (e.g., patient symptoms)?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in reviewing and reporting subclavian steal?
- Identify any challenges you experienced, such as needing to seek advice or clarification on a complex waveform or escalating an associated 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 your diagnostic approach to proximal arch disease.
- What will you do differently next time you approach reviewing or reporting the subclavian steal phenomenon, for instance, by proactively reviewing the haemodynamic principles and diagnostic criteria for partial and complete subclavian steal?
- Do you need to practise any aspect of the activity further, such as interpretation of complex waveforms associated with steal?
Beyond action
Have you revisited the experiences?
- How have your subsequent experiences of reviewing and reporting on subclavian steal phenomenon 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 differentiation between partial (pre-steal) and complete subclavian steal forced you to re-evaluate the diligence of your vertebral artery waveform analysis and reporting terminology you applied during your first attempt at classification.
- Considering what you understand about haemodynamics of subclavian steal, flow direction quantification, and application of specific waveform criteria 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 reporting methodology for subclavian steal based on further learning and experiences? For example, how you proactively integrated the standardized four-stage grading system for flow reversal into your reporting template to ensure consistency in describing the phenomenon, demonstrating you have adapted improvements based on further learning.
- Has discussing ambiguous cases of partial steal or the impact of incorrectly classifying flow reversal 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 subclavian steal was initially missed refined your understanding of the critical nature of systematic upper limb arterial assessment.
How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent subclavian steal reporting experiences, contributed to your overall confidence and competence in reviewing and reporting ultrasound findings with subclavian steal phenomenon, particularly in preparing for assessments like Direct Observations of Practical Skills (DOPS) or Case-Based Discussions (CBDs)? For example, how your accumulated ability in vertebral artery assessment now enables you to confidently identify and assess retrograde flow 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 reviewing and reporting ultrasound finding with subclavian steal phenomenon? 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 associated finding suggests a potentially acute vertebral artery dissection complicating the diagnosis of steal, recognising this requires urgent clinical input.
- Looking holistically at your training journey, how has this initial subclavian steal reporting experience, revisited with your current perspective, contributed to your development in meeting the objectives related to analysing and interpreting the ultrasound findings? For example, how this foundational experience has supported your development in applying ultrasound physics to correctly optimise the scan.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 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. |
| # 5 |
Outcome
Produce an interpretive clinical report of the extracranial arterial scan findings. |
| # 8 |
Outcome
Critically evaluate the clinical significance of incidental findings. |