Trudie Young: Should we perform a Doppler assessment on everyone?

We started the day discussing the problems with the Ankle Brachial Pressure Index because there's always going to be a certain group of patients that we can't do it. It might be too painful for them, their legs might be too swollen, the nurse might not have the experience and there might not be the equipment available. So although the workshop was about the ABPI, we started talking about the importance of doing a full lower limb assessment, at arterial risk factors and venous risk factors so that we get a picture whether we've got an arterial problem or a venous problem before we ever get to the ABPI because we were quite conscious that people focus on the ABPI as a main diagnostic indicator when in fact it's only there to confirm your clinical assessment. So we tried to put it into context and into perspective. As I say we talked about the problems there are before and when you can't do an ABPI. We We talked about other methods such as palpation of foot pulses and capillary refill and we looked at that. We also discussed the pole test, so alternative methods when you have got problems doing ABPIs. Well with the pole test you have your patient lying flat and there's a measurement pole on the wall and what you do, you locate the dorsalis pedis pulse with a handheld Doppler machine. Then slowly you keep your Doppler probe on your dorsalis pedis and you lift the patient's leg up. And if the leg is elevated and you can still hear the pulse, you probably have not got arterial problems. So it's a way of doing it if you cannot put a cuff around someone's leg, you can still use a probe to help you listen to the pulse. We did demonstrate an automated system in the session. And very much the automated systems are what were quite a quick way of doing it because you don't have to rest your patience. Some use sounds, some use oscillation, some use four, two cuffs on the leg, two on the arms, some are only a three cuff system. So there are lots of different systems out there, but they work in different ways. The one thing that we felt perhaps is a slight hindrance is that you're not actually listening to the sounds. So you're not actually listening to that pulsatile sound. So we felt that sometimes that was a disadvantage. So we felt that the more automated systems, as good as an initial system may be, and then after that go on and do a more extensive handheld assessment because you cannot get everything from the automated systems. So we felt they had some advantages but there were also some limitations. Then other people would use it the other way around and what they would do would do a full handheld assessment initially to get a complete picture and they then might use the automated systems for re-Dopplering and follow-up checks. And again, there are certain patients when you're doing your different assessments, you'll think, well, I do want to listen to the pulses. Others, you'll think they've got no arterial risk, their Doppler readings are fine, and I might be quite happy with an automated system. But it's always to be aware with the automated systems that there are other extensions to that assessment that you might well need to do to make sure your assessment is truly holistic and complete. Again, if we found that patients had got very low ABPIs of course we have to refer to our vascular colleagues, we need to get them treated as soon as possible. We did discuss in the session though that if patients have got mixed aetiology leg ulcers that people sometimes then would refer on for further vascular assessment but we did talk about having some kind of assessment and management while we're waiting so that the oedema is not getting worse and the ulcer is not getting worse. So we talked a lot about the role of reduced compression in in patients with mixed aetiology. So just because they had arterial disease it didn't mean we did nothing but we did the appropriate care while we're waiting for more extensive referral or assessment.