DDU(Vascular) - Australasian Society for Ultrasound in Medicine

ASUM is the Peak Body for Medical Ultrasound in Australia and New ZealandDiploma of Diagnostic Ultrasound (DDU)DDU(Vascular) SyllabusContentsPageIntroduction: Who is the DDU(Vascular) for? 2− Overall Objectives 2MODULE 1: Foundations of Ultrasound Practice 3PART A: Physics and Instrumentation 3− Rationale 3− Aim 3− Learning Objectives 4− Suggested Topics to Review 6PART B: Principles of Image/Data Collection and Optimisation 11− Rationale 11− Aim 11− Learning Objectives 11PART C: Professional, Ethical and Legal Issues 12− Rationale 12− Aim 12− Learning Objectives 12MODULE 1: Suggested Reading and Resource List 13MODULE 2: Clinical Competence 15MODULE 3: Advanced Ultrasound Practice 16− Learning Objectives 16− Major Topics 17MODULE 3: Recommended Reading List 19DDU(Vascular) Syllabus 2012.08.06 V2

DDU(Vascular) SyllabusIntroduction: Who is the DDU(Vascular) for?A DDU certified doctor is a specialist medical practitioner who has overall responsibilityfor ensuring the most accurate and valid information possible is obtained from theultrasound examination. The DDU holder is then responsible for using the acquiredinformation to meaningfully contribute to clinical patient management. The DDU holderwould usually have diagnostic ultrasound as a major focus of their practice and acceptreferrals from a range of other medical practitioners as well as self-referrals.The DDU holder has detailed specialist level knowledge and skill in all aspects of thediagnostic ultrasound process. This knowledge and skill may also apply to therapeuticinterventions/processes.Candidates for the DDU (Vascular) would usually be specialist medical practitioners whohave a special interest and expertise in all aspects of vascular diagnosis with a particularemphasis on ultrasound. It is expected that candidates would be working predominantlyin the area of vascular ultrasound and be able to develop in-depth knowledge andexperience suitable for specialist level referral practice in vascular diagnosis andultrasound.OVERALL OBJECTIVESMODULE 1: Foundations of Ultrasound PracticeOn completion of this module of study you will have demonstrated your knowledge of:• Physics and instrumentation• Principles of image/data collection and optimisation• Professional, ethical and legal issuesby successfully completing a written assessment.MODULE 2: Clinical CompetenceOn completion of this module of study you will have demonstrated scanning anddiagnostic competence by successfully undertaking and completing:• Five (5) Case Studies• Five (5) Clinical Supervisor Assessments• A logbook of specified scansMODULE 3: Advanced Ultrasound PracticeOn completion of this module of study you will have demonstrated your theoreticalknowledge and advanced diagnostic and practical skills by successfully undertaking andcompleting:• A written assessment• An oral assessment2

DDU(Vascular) SyllabusLEARNING OBJECTIVESPhysical principles of ultrasoundCandidates will be able to describe:• the wave nature of ultrasound and its propagation through tissue.• the reflection and scattering of ultrasound and relate these to acoustic impedance.• the concept of attenuation, its mechanisms and factors affecting it.• refraction of ultrasound and critical angle of incidence.• the concept of pulsed ultrasound.• the concept of the bandwidth of an ultrasound pulse.Transducer and beamforming conceptsCandidates will be able to describe the:• purpose and function of a transducer and the construction of a typical transducer.• concept of an ultrasound beam and the importance of controlling beam width.• beam shape for a simple unfocused transducer.• various methods used to focus the beam, including electronic focussing for arraytransducers.• major types of transducer and the mechanisms used with each to scan the beamwhen imaging.• concept of slice thickness.Candidates will be able to:• define beam sidelobes.• explain the factors affecting the choice of transducer for a specific application.Imaging principles and technologyCandidates will be able to describe the:• pulse-echo principle and how it is used in B-mode and M-mode ultrasound imaging.• basic components of an ultrasound imaging machine and their purpose.• controls associated with each component and their effect on the image.• methods used to make measurements from images.• various methods available to record imagesCandidates will be able to:• define the major aspects of image quality.• recognise the principal image artifacts and describe how they are produced andhow they can be identified and/or eliminated.4

DDU(Vascular) SyllabusDoppler principles and instrumentationCandidates will be a able to describe the:• principle of operation and components of continuous wave and pulsed Dopplerinstrumentation.• elements of the Doppler spectral display and how it is used to make measurements.• principle of operation and components of colour Doppler.• instrumentation, including power (amplitude) mode.Candidates will be able to:• explain the Doppler effect and describe how it is used in ultrasound diagnosis.• recognise the principal Doppler artifacts and describe how they are produced andhow they can be identified and/or eliminated.Bioeffects and safetyCandidates will be able to:• demonstrate an understanding of the potential for bioeffects and biohazards.• define the parameters used to characterise patient exposure.Candidates will be able to explain:• the known thermal and mechanical bioeffects and the relative likelihood of theseoccurring with different modes of examination.• practical approaches to reducing risk and relevant ASUM policies.New and evolving techniques• Candidates will be able to discuss briefly the basic principles involved in a range ofnew technologies including:- multiple beamforming- extended field of view- contrast agents- tissue and contrast harmonic imaging- spatial compound scanning- three dimensional (and 4D) scanning- coded signals- Doppler tissue imaging- elastography.5

DDU(Vascular) SyllabusSUGGESTED TOPICS TO REVIEWPhysical principles of ultrasoundDescribe:Calculate:- frequency, wavelength, period- propagation speed- amplitude, energy, power, intensity- attenuation, relationship between frequency and penetration- acoustic impedance- reflection, scattering- refraction, critical angle- pulsed ultrasound, pulse repetition frequency, pulse duration- relationship between period and frequency: =- relationship between frequency, wavelength & propagation speed:- intensity: = λ = - attenuation as a function of tissue type, frequency and distance = × × - intensity reflection coefficient: = − ² + ² × %- refraction using Snell’s Law: = - gain and attenuation using decibel notation6

DDU(Vascular) SyllabusTransducer and beamforming conceptsDescribe:Calculate:- piezoelectric effect, transducer resonance- transducer construction, backing and matching, coupling gel- transducer bandwidth, relationship to pulse duration- broadband transducers- unfocussed transducer beam pattern, near and far fields- focussing using lens or curved transducer- focussed transducer beam pattern- weak, medium and strong focusing- array transducer construction- electronic focussing using array transducers- electronic beam steering- sidelobes, slice thickness- variation of intensity with depth and across width of beam- major probe types - linear, curved and phased arrays- scan patterns of major probe types- factors affecting choice of transducer for given application- transition distance (near field length): = λ- far field divergence: = . λ- beamwidth at focus (of focussed transducer) =. λImaging principles and technologyDescribe:- pulse echo concept (relationship between echo time and depth)- image formation, B and M-mode- function, purpose and associated controls of:• transmitter• beamformer7

DDU(Vascular) Syllabus• amplifier, TGC• digitisation• dynamic range compression• scan converter• pre-processing• image memory• post-processing• display- meaning of term ‘artifact’ and reasons why artifacts occur- mechanism of production and typical appearance of:• shadowing• enhancement• edge shadowing• reverberation• comet-tail• ringdown• depth error• beamwidth artifact• sidelobe artifact• slice thickness artifact• refraction• mirror image• artifacts due to wrong equipment settings• artifacts due to equipment failure and electrical interference- use of some artifacts as diagnostic signs- distance and area measurement- calculation of volume- limitations on accuracy of measurements- image storage and recording techniques, including:• single image vs cine loop• digital storage in machine or on network• storage on CDs, DVDs etc• video recording• hard copy on film and paperCalculate:- relationship between echo arrival time and depth: = - relationship between penetration, line density and frame rate: × × = = , /8

DDU(Vascular) SyllabusDefining equipment performanceDescribe:Calculate:- axial resolution- lateral resolution- contrast resolution, improvement through reduction of artifacts- temporal resolution, methods to improve- axial resolution from pulse duration:axial resolution = Doppler principles and instrumentationDescribe:Calculate:- Doppler effect- the Doppler angle and its implications- principles and controls of:• continuous wave Doppler• pulsed Doppler• Doppler spectral display• colour Doppler, including power mode colour Doppler- limitations of each Doppler modality- Doppler artifacts, including:• frequency aliasing and ways to reduce or eliminate it• range ambiguity• intrinsic spectral broadening• spectral mirror artifact• wall thump• twinkle artifact- standard Doppler measurements:• velocity• spectral broadening, relationship to turbulent flow• Resistance Index and other commonly used indices- be able to use the Doppler equation: = 9

DDU(Vascular) SyllabusBioeffects and safetyDescribe:- importance of bioeffects and safety- current knowledge based on epidemiology and clinical experience- difference between bioeffects and biohazards- known mechanisms and factors affecting them:• thermal effects• cavitation• other mechanical effects- ultrasound output measurement- parameters used to characterise exposure:• pressure, power and intensity• spatial and temporal variation of intensity• I spta , I sptp , I satp , I sata - definitions and relative magnitudes- comparison of exposure levels associated with different operatingmodes: 2D imaging, M-mode, cw and pulsed Doppler etc- Thermal and Mechanical Indexes - purpose and interpretation- practical approaches to minimising risk- ALARA principle- ASUM policy statements and guidelinesNew and evolving techniquesDescribe:- principles, advantages and limitations of:• compound scanning• tissue harmonic imaging• panoramic scanning (extended field of view)• ultrasound contrast agents• 3D and 4D scanning• 1.5D and 2D array transducers (matrix arrays)• coded signals• Doppler tissue imaging• elastography10

DDU(Vascular) SyllabusPart B: Principles of Image/Data Collection andOptimisation(15% Weighting)RATIONALEThe aim of any ultrasound examination is to produce accurate, valid and clinically usefulinformation. In achieving this aim all professionals involved in the ultrasound examinationmust have adequate underpinning knowledge and skill in: ultrasound physics andinstrumentation (Part A of this syllabus); the major techniques used, principles appliedand potential pitfalls encountered in producing an examination; the standard terminologyand principles of reporting information used to describe ultrasound appearances and thecare and maintenance of the equipment to ensure safe and accurate use.AIMFor the candidate to demonstrate knowledge and application of the principlesunderpinning the production of an accurate and valid ultrasound examination that can beused as foundational knowledge for ongoing practice in the field of diagnostic ultrasound.LEARNING OBJECTIVES1. Describe a range of techniques that can be used to ensure the best qualityexamination is obtained including: patient positioning and breathing; thoroughsystematic scanning throughout relevant organs/structures.2. Describe and be able to apply a range of probe manipulation techniques in orderto produce an accurate, valid and efficient examination.3. Define and be able to recognise standard scan planes, image orientation andassociated terminology used in general ultrasound applications and recognisewhere there may be variations used in particular fields (eg intracavity scanningand cardiac ultrasound).4. Describe the principles of adequate documentation of ultrasound images and dataincluding labelling of images/data, and recording and archiving methods.5. Define and be able to accurately apply standard terminology used to describeultrasound appearances.6. Describe the use of, and be able to apply, equipment controls to optimise thequality of the images/data produced including: time gain compensation (TGC);power/”gain”; focus; depth and zoom; principles of measurement to enhanceaccuracy.7. Describe the general principles of ultrasound guidance for interventionalprocedures.8. Describe general principles of care and maintenance of equipment.9. Describe and be able to apply principles of infection control in the use ofultrasound and its associated equipment.11

DDU(Vascular) SyllabusPart C: Professional, Ethical and Legal Issues(15% weighting)RATIONALEThe effective use of ultrasound examinations and procedures to contribute to clinicalmanagement of patients includes many aspects of the process. Along with technicalaspects of the production of the examination, all professionals using ultrasoundtechniques need to ensure that the examination is conducted in a way that meets legal,ethical and professional standards. All professionals using ultrasound techniques areresponsible for ensuring they have adequate and up-to-date knowledge of all aspects ofthe ultrasound examination process and associated legal and ethical requirements.Where other professionals are involved in the performance of any aspect of theultrasound examination process it is a professional obligation of the responsible clinicianto be aware of the role, functions, capabilities and responsibilities of all members of thecontributing team.AIMFor the candidate to demonstrate knowledge of the broad professional, ethical and legalprinciples and requirements that are particularly applicable to ultrasound practice asfoundational knowledge for ongoing practice in the field of diagnostic ultrasound.LEARNING OBJECTIVES1. Describe, in broad terms, the principles, importance and applicability of legal issuesand requirements relevant to ultrasound practice including:a. Professional indemnity insurance;b. Vicarious liability, particularly as relevant to other staff eg sonographers;c. Issues of negligence, including malpractice and mis-diagnosis;d. Report writing standards and requirements;e. Data record keeping and archiving requirements;f. Electronic transmission and storage of data including Picture Archiving andCommunication Systems (PACS), telemedicine and other means of data transfer;g. Privacy and confidentiality issues, including those related to electronic transmission ofdata;h. Legislative requirements for Medicare rebatable examinations including equipmentrequirements, practice standards etc.2. Describe, in broad terms, the principles, importance and applicability of ethicalconsiderations relevant to ultrasound practice including:a. Principles of biomedical ethics;b. Informed consent, particularly for "screening" procedures and invasiveexaminations;c. Communication, including limitations of the examination/procedure;d. Privacy and confidentiality issues.12

DDU(Vascular) Syllabus3. Describe, in broad terms, the principles, importance and applicability of issues andrequirements of health professional regulation and other professional issues relevantto ultrasound practice including:a. Registration and continuing professional development (CPD) for doctors;b. Registration and continuing professional development (CPD) for sonographersand other relevant staff;c. Sources of published standards of practice and relevant professionalorganisations;d. Incident reporting obligations, both mandatory and voluntary;e. Occupational health and safety issues;f. Quality control and processes for auditing of all aspects of ultrasound practice.MODULE 1: Suggested reading and resources listPart A: Ultrasound Physics and InstrumentationEssential ReadingGill, Robert (2012) The Physics and Technology of Diagnostic Ultrasound: APractitioner’s Guide. High Frequency Publishing. ISBN 9780987292100. Available via theauthor’s website http://ultrasoundbook.netSupplementary ReadingKremkau, F.W. (2011) Sonography: Principles and Instruments (8 th edition). Saunders.ISBN 9781437709803Necas, Martin (2012) Artifacts in Diagnostic Medical Ultrasound: Volume 1 GrayscaleArtifacts. ISBN 9780473215651. Available as an e-book from the Apple iBookstore or asa printed book or pdf e-book from the author via info@antegrade.netGent, R. (1997) Applied Physics and Technology of Diagnostic Ultrasound. OUT OFPRINT but available as a PDF on CD through ASUM and still widely available in libraries.To order please refer to the ASUM website www.asum.com.auHedrick, W.R., Hykes, D.L. and Starchman, D.E. (2005) Ultrasound Physics andInstrumentation (4th edition). Elsevier Mosby.ASUM Online Physics Tutorial (To access please refer to your confirmation ofenrolment)Hoskins, P.R., Thrush, A. and Martin, K. (2010) Diagnostic Ultrasound: Physics andEquipment (2nd edition). Cambridge University Press. ISBN 052175710X.13

DDU(Vascular) SyllabusPart B: Principles of Image/Data Collection and OptimisationAmerican Institute of Ultrasound in Medicine (AIUM) Practice Guideline forDocumentation of an Ultrasound Examination Original copyright 2002; revised 2008,2007 (Please refer to the AIUM Website www.aium.org)American Institute of Ultrasound in Medicine (2008): Recommended UltrasoundTerminology, Third Edition (Please refer to the AIUM Website www.aium.org)Hagen-Ansert S (2011) Textbook of Diagnostic Ultrasonography 7 th Edition MosbyElsevier, St Louis (good general text for scan techniques and "how to scan").Tempkin B (2009) Ultrasound Scanning: Principles and Protocols 3 rd Edition SaundersElsevier, St Louis (good general text for scan techniques and "how to scan").ASUM Policies and Statements (Please refer to the ASUM Website www.asum.com.au)Part C: Professional, Ethical and Legal IssuesForrester K and Griffiths D (2005) Essentials of Law for Health Professionals 2nd EditionMosby Elsevier Sydney (in this edition particularly chapters 4,5,6 related to legalconcepts for health professionals).Kerridge I, Lowe M and McPhee J (2008) Ethics and Law for the Health Professions 2ndEdition Sydney (in this edition particularly chapters 9, 10, 12,13, 14).Australasian Sonographer Accreditation Registry (ASAR) at www.asar.com.auAustralian Health Practitioner Regulation Agency (AHPRA) at www.ahpra.gov.auHuang SJ, McLean AS (2010) Do we need a critical care ultrasound certificationprogram? Implications from an Australian medical- legal perspective. Critical Care14:313. (although aimed at critical care specialists many relevant points for ALL DDUcandidates).Please refer to the Australasian Legal Information Institute(AustLII) websitewww.austlii.edu.au (database of Australian legal cases where full details of negligenceand other cases before tribunals, courts etc can be found. Can search for cases using"ultrasound". (For interest and information only).14

DDU(Vascular) SyllabusMODULE 2: Clinical CompetenceModule 2 Clinical Competence is designed to assess the overall clinical ultrasoundcompetence of the DDU candidate in the workplace/clinical setting and includesassessment of a wide range of required knowledge, skills and abilities as defined by therelevant specialty syllabus for Module 3. Candidates must familiarise themselves with thespecific learning objectives, required abilities and major topic areas coveredModule 3.Assessment for Module 2 Clinical Competence is achieved via a variety of techniques toenable an accurate assessment of the candidate’s overall clinical ultrasoundcompetence. The assessment methods used offer a balance between adequateassessment of knowledge, skills and abilities, and practicality and feasibility.To assess Clinical Competence the following assessments will be used:The Module 2 assessments are:i. Two (2) formative Case Studies (1st year)ii. Two (2) formative Clinical Supervisor Assessments (1st year)iii. Three (3) summative Case Studies (2nd year)iv. Three (3) summative Clinical Supervisor Assessments (2nd year)v. A Logbook with specified numbers and types of scans to be completedvi. The completion of two (2) years diagnostic ultrasound experience15

DDU(Vascular) SyllabusMODULE 3: Advanced Ultrasound PracticeLEARNING OBJECTIVESIn order to successfully complete the DDU (Vascular) candidates are expected to be ableto demonstrate, in relation to the list of major clinical areas as listed under “MajorTopics”, the following:• Ability to obtain a detailed, relevant clinical history.• Ability to conduct the ultrasound examination in an appropriately effective mannertaking into consideration the environment, and the patient’s privacy, cultural andreligious needs.• Understanding of, and skills involved in, producing and recognising an accurateand valid ultrasound examination and resultant data, including protocols for, andnormal ranges of, standard measurements and haemodynamic spectral analysisincluding calculations/indices.• Detailed knowledge of relevant: anatomy; physiology; haemodynamics; andpathology.• Detailed knowledge of other diagnostic methods used in vascular diagnosisincluding: ankle-brachial index (ABI); exercise testing; plethysmography;angiography and venography; magnetic resonance angiography (MRA) andcomputed tomography angiography (CTA).• Ability to determine the need for further information such as: extension of theultrasound examination; other tests; further clinical information; follow-upexaminations.• Competence in the recognition of sonographic appearances and relevantinformation including: normal anatomy, physiology and hemodynamics; normalvariants; artifacts; abnormalities of vascular structure, course of vessels,haemodynamics and function.• Detailed knowledge of vascular non-surgical treatments, surgical andinterventional procedures and the relationship of these to ultrasound assessmentand diagnosis.• Competence in determining appropriate provisional diagnosis/diagnoses as aresult of the ultrasound examination and in conjunction with other available clinicalinformation as relevant.• Appreciation of the more rarely seen/uncommon pathologies which may beassociated with the vasculature and related structures.• Ability to perform and/or be able to interpret advanced ultrasound techniques suchas contrast studies and 3D ultrasound as and when required to aid in thediagnosis.• Recognition of any limitations of the ultrasound examination, including technicallimitations and artifacts, and the effect of these on diagnosis and clinicalmanagement.• Ability to prepare a detailed report including information on findings/diagnoses,any limitations of the examination, correlation of findings with other relevantinformation, requirements/suggestions for further testing or follow-upexaminations.16

DDU(Vascular) Syllabus• Ability to be able to communicate effectively with the patient/client and/or theiraccompanying persons in a manner that is timely, relevant and appropriate to thecircumstances, where required.• Ability to identify and act appropriately to ensure timely medicalreview/intervention where an urgent finding is made.• Understanding of the applications of new and advanced techniques such as intravascularultrasound and other techniques as they become available for clinicaluseage.MAJOR TOPICSIntroduction:The DDU (Vascular) candidate is expected to have a deep level of knowledge across abroad range of clinical applications of diagnostic ultrasound irrespective of whether or notall topic areas would usually be expected to be covered by the candidate during thecourse of their professional practice.Candidates are expected to read widely and seek a range of learning opportunitiesincluding those focussed on theoretical and clinical learning, and practical skillsdevelopment in order to be able to demonstrate competence across the syllabus.Vascular Ultrasound:A candidate is expected to be able to competently undertake a vascular ultrasoundexamination, including at least the following abilities:1. Perform and interpret the ultrasound examination using any combination oftechniques such as: B-mode; Doppler (continous wave, pulsed and continuouswave spectral, colour, and amplitude or “power”), clinical evaluation and exercisetesting as required by the presenting circumstances.2. Perform and interpret haemodynamic spectral analysis demonstrating a detailedknowledge of the principles, applications and limitations of all commonly usedcalculations/indices and diagnostic criteria (as described by published standardsand protocols).3. Perform interventional techniques when required by the presenting circumstances.The candidate is expected to be able to demonstrate a detailed knowledge andunderstanding of the role of ultrasound in assessment of, at least, the following:1. Cerebrovascular arterial circulation including:a. Extracranial carotidb. Extracranial vertebralc. Intracranial arteries assessible by trans-cranial ultrasound techniques.2. Vessels of the thoracic outlet (brachiocephalic and subclavian arteries and veins).17

DDU(Vascular) Syllabus3. Upper limb arterial system; including those used for vascular access forhaemodialysis and other treatments.4. Abdominal aorta and its major branches including: visceral, renal and iliac arteries.5. Pre and post-operative vascular ultrasound information for organ transplants.6. Lower limb arterial system including post-intervention states.7. Upper limb venous system.8. Lower limb venous system.9. Intra-abdominal veins including: portal venous system; mesenteric; renal; iliac;inferior vena cava.10. A wide range of possible vascular pathologies and conditions including at least;a. atherosclerosisb. thrombosis (arterial and venous)c. aneurysmd. vasculitise. traumaf. dissectiong. arteriovenous malformation, fistuale and vascular neoplasms (eg carotidbody tumour)h. entrapment syndromesi. fibromuscular dysplasiaj. neointimal hyperplasiak. vasospastic diseasesl. other uncommon arteriopathiesm. venous incompetencen. cardiac and other conditions which may affect haemodynamic function (egcardiomyopathy, chronic cardiac failure, severe aortic stenosis, severetricuspid regurgitation, aortic coarctation, Marfan’s syndrome etc).11. Vasculogenic impotence.12. Lymphatic system.13. Paediatric vascular conditions.14. Quality control processes required to maintain the accuracy of vascularassessment and diagnosis.Principles of Interventional Ultrasound:1) Understanding of the principles and processes for ultrasound guided proceduressuch as sclerotherapy, endovenous laser, interventional therapeutic procedures,and vascular access procedures.18

DDU(Vascular) SyllabusMODULE 3: Recommended Reading ListCore Texts:Zwiebel, W. J. & Pellerito, J. (2004). Introduction to Vascular Ultrasonography (5th ed.).Saunders W B Co Ltd.Meissner, M., Zierler, R. E. (Eds). (2010). Strandness's Duplex Scanning in VascularDisorders (4th ed.). Lippincott Williams & Wilkins.Myers, K., & Clough, A. (2004). Making Sense of Vascular Ultrasound: A Hands-OnGuide. Hodder Arnold.Core References:i. Journal of Vascular Ultrasoundii. Journal of Vascular Surgeryiii. European Journal of Vascular and Endovascular Surgery19