915 BL

PARKS
915-BL Dual-Frequency Doppler

Operating/Service Manual
The 915-BL Dual-Frequency Doppler is two Dopplers in one case. The low-frequency nominal 2 MHz
precordial probe may be used to detect the passage of air emboli in the heart. The high-frequency nominal
8-9 MHz pencil probe is used for systolic pressures at sites where a stethoscope is not used, as well as
to detect blood pressures that are too low for a stethoscope to auscultate. This probe can also be used to
listen for blood flow and pulses distal to arterial repair.
A built-in cautery suppressor with a controllable threshold shuts off the sound when the interference gets
too high.
Read this manual prior to use.

Follow manufacturer’s guidelines for safety and maintenance of equipment.
This instrument was manufactured to comply with all relevant national or international regulations and
left the factory in safe condition. In order to keep this instrument in a perfect and safe condition, it is up
to the user to observe all instructions and warnings included in this manual.
915-BL, UNM 5.5 6/2012 915-BL Dual Frequency Doppler 1

2 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.
Table Of Contents
Introduction Maintenance and Service

Installation and Setup ............................................ 4 Cleaning the Instrument ...................................... 15
Safety .................................................................... 4 Cleaning the Probes ............................................ 15
Instrument Identification Information ..................... 4 Tuning ................................................................. 15
Routine Maintenance .......................................... 15
Equipment Description
Replacing the Battery .......................................... 16
Probes .................................................................. 6
Replacing the Fuse ............................................. 16
Battery Charger ..................................................... 7
Technical Support and Service ............................ 16
Cautery Suppressor .............................................. 7
Troubleshooting Guide ........................................ 17
Optional Headphones............................................ 7
Technical Information and Notes
Operating Instructions
Specifications .................................................... 20
Setting Up the Instrument...................................... 8
Warranty .............................................................. 21
Using the Coupling Gel ......................................... 8
Physiological Effects of Ultrasound ..................... 21
Using the Probe..................................................... 8
Environmental Hazards ....................................... 21
Using the Cautery Suppressor .............................. 9
Electrical Safety................................................... 22
Shutting Down the Instrument ............................... 9
Ordering Information and Replacement Parts ..... 23
Charging the Battery ............................................. 9
Contact Information ............................................. 23
Diagnostic Procedures
Appendix
Performing Diagnostic Procedures...................... 10
Acoustic Output Power ....................................... 25
Detecting the Passage of Air Emboli in the Heart..... 10
Practical Office Technics for
Positioning the Precordial Probe ......................... 10
Physiologic Vascular Testing ............................... 32
Taking Blood Pressure (BP) Measurements ....... 10
Measuring Systolic Pressure ................................11
Lower Extremity Arterial Evaluation......................11
Preoperative and Postoperative Blood Pressure
(BP) Measurements ............................................ 13
Upper Extremity Arterial Evaluation..................... 13
Venous Evaluation............................................... 13
References .......................................................... 14
915-BL Dual Frequency Doppler 3

Introduction
Installation and Setup
Unpack the instrument and accessory equipment from the packing box.
The 915-BL kit includes:
915-BL Dual-Frequency Doppler
2.1-2.25 MHz (Specified) Precordial Probe
8.0-9.9 MHz (Specified) Pencil Probe or Adult Flat Probe
24VDC 0.63 A Battery Charger
Ultrasound Transmission Gel, 0.25 L
Operating/Service Manual
Place this instrument on a clean, nonconductive, level surface.

The instrument should not be placed near devices which may cause radio interference or grounding.
The Doppler unit is shipped fully charged and ready to use.
Read the Operating Manual prior to using instrument.
Safety
This instrument is intended for use by health care professionals only.
The following symbols are used throughout this manual:
CAUTION: Indicates a potentially hazardous situation that, if not avoided, could result in personal
injury or damage to the instrument.
DANGEROUS VOLTAGE: Indicates a potential electrical hazard that, if not avoided, could result in
personal injury or damage to the instrument.
TYPE B APPLIED PART

MEDICAL EQUIPMENT
Type B Applied Part: complies with degree of protection against electric shock required by IEC 60601-1.
Class IIa Equipment:
This noninvasive ultrasound Doppler meets the safety requirements specified for a Class IIa active
medical device.
Acoustic Output Power is within limits set by the FDA and the European Union.
This device is intended for vascular studies. It is not intended for obstetrical use.
Parks Medical Electronics, Inc. manufactures a complete line of obstetrical Dopplers.
Instrument Identification Information

Write the information from your instrument bar code label here or on the parts page for reference when
reordering parts or requesting technical support:
Serial Number Part Number
Model Date of Manufacture
Date instrument purchased Customer Number

DUAL-FREQUENCY DOPPLER
MODEL 915-BL
1 0197
PARKS MEDICAL ELECTRONICS, INC.
ALOHA, OREGON U.S.A.
FLASHING LIGHT
INDICATES LOW
BATTERY TYPE B
APPLIED PART
MEDICAL EQUIPMENT
2 LOW
OW H
HIGH
VOLUME
ON
N OFF O
ON
11
3 SUP. ON
S 10
9
PROBES
SUP. OFF
SUP
CAUTERY SUPPRESSOR
24 V CHARGER HEADPHONE
HEADPHONES
4 2.1 MHZ 8.3 MHZ
0 63 A
0.63
KEEP ON CHARGE
HARGE WHEN NOT
OT IN USE
5 6 7
Front Panel
1. Manufacturer’s Label 7. Battery Charger Jack
Lists serial number (SN), part number, 24 V
0.63 A
The battery charger plugs into this jack.
model, and date of manufacture. 8. Headphone Jack
2. Battery Indicator Lamp Optional headphones plug into this jack.
This lamp lights when the unit is turned on. 9. Cautery Suppressor Control Knob
Blinking lamp warns battery needs charging. This knob controls the amount of cautery
3. Power Control Knob noise that is cut out.
The center position turns instrument off. The full counterclockwise position turns the
Turn switch to the left for 2 MHz probes. cautery suppressor off (SUP OFF).
Turn switch to the right for 8 MHz probes. Turning the knob clockwise cuts out more
4. 2.1-2.25 MHz (Specified) Probe Jacks noise.
The low-frequency precordial probe 10. Cautery Suppressor Indicator Lamp
plugs into these jacks. This indicator lamp is lit only when the
5. 8.0-9.9 (Specified) MHz Probe Jacks cautery suppressor is on (SUP ON).
The high-frequency pencil probes and flat 11. Volume Control Knob
probes plug into these jacks. This knob controls the Doppler sound level.
6. Battery Charger Indicator Lamp Turning the knob clockwise increases the
This lamp lights when the unit is charging. volume.

Probes
Each probe consists of two crystals; one transmits ultrasound waves and one receives the reflected
waves. The initial energy beam is as wide as the crystal. The probe’s two connectors can be plugged into
either of the two jacks on the Doppler that match the probe frequency. The Doppler is tuned to the probe
frequency. The frequency is identified on the panel next to the jacks and on the label attached to each
probe cable.
Damage to either crystal will impair or prevent probe function. The material covering the crystals can be
damaged by abrasion, soaking in alcohol or cleansers, and excessive heat.
The 915-BL comes with a 2.1-2.25 MHz (frequency specified) precordial probe and either a 8.0-9.9
MHz (frequency specified) standard pencil probe or flat probe. The precordial probe is used to detect air
emboli in the heart. The pencil probe is used to detect blood flow and monitor systolic blood pressure in
the legs. The flat probe is designed to be taped on the wrist for repeated blood pressure measurements.
Probes with double-shielded

cables can be ordered for use
in locations with high levels of
electrical interference.
Standard Pencil Probe Precordial Probe

(an option with kit) (included with kit)
Frequency: 2.1-2.25 MHz (Specified)
Frequency: high: 8.0-9.9 MHz (Specified) Diameter: 3/4 in
Diameter: high: 3/8 in Cable length*: 5 ft standard (Double Shielded)
Cable length*: 5 ft standard May be used for detecting air emboli in
Standard diagnostic probe. the heart.
Skinny Pencil Probe
(optional at additional cost)
Diameter: 1/4 in
Cable length*: 5 ft standard
The smaller probe crystal concentrates power to produce a beam with higher
intensity than the standard probe, providing better resolution for small vessels.
Flat Probes
Infant Adult
(an option with kit)
Size: Adult 5/8 in X 3/4 in; Infant 1/2 in X 5/8 in
Cable length*: 5 ft standard
Crystals are set into the plastic so that the ultrasound beam goes into the vessel at about 15 degrees
from perpendicular. Flat probes are easily taped into place for taking repeated measurements.
*7 and 10 ft cable lengths are available by special order. Doppler must be tuned to probes with longer cables.

Battery Charger
The Doppler comes with a 24VDC 0.63 A battery charger; the charger plugs into the front of the
Doppler and must be connected to an AC power supply (appropriate wall plug adapter must be used for
outlets other than 120 V). The Doppler battery cannot be overcharged. The Doppler cannot be operated
while it is connected to the battery charger.
Battery Life
Battery life between charges for a new battery will be more than 16 hours on a full charge. The battery
life will decrease as the battery ages or if it is not kept fully charged.
With normal service and care, a battery can be expected to last two to three years. Leaving the battery
discharged for days will shorten the life of the battery.
Cautery Suppressor
Under normal operating conditions, the cautery suppressor is off.
Use of the Doppler in the presence of a cautery can cause interference. A cautery generates sound over
a wide band of frequencies that cannot be filtered by the Doppler. The frequencies close to the probe
frequency will be picked up by the probe wires and transmitted to the Doppler speaker. Experimenting
with placement of the probe cable and the Doppler can minimize cautery interference, but not eliminate
it. The cautery suppressor is designed to shut off sound to the Doppler speaker or headphones when the
volume of the cautery interference exceeds that of the blood flow or air emboli detected by the probe.
The control knob for the cautery suppressor is on the front panel of the Doppler. The cautery suppressor
is off when the cautery suppressor control knob is turned all the way counterclockwise. Turning the knob
clockwise increases the level of suppression.
Headphones
The speaker is disconnected when the optional low impedance stereo headphones are plugged in. You will
always hear more through the headphones, especially when checking weak flow or veins.

Setting Up the Instrument
1. Place the instrument near the patient to be tested.
▪ The instrument should not be placed near devices which may cause radio interference.
▪ The instrument should not come into contact with metal surfaces or other electronic devices.
2. Plug the desired probe into the correct MHz jacks; the probe cable connectors can plug into either
jack of the same frequency. The probe frequency is identified on the panel and on the probe label.
3. Remove the red protective cover from the probe tip prior to use.
Using the Coupling Gel

The probes require a conductive medium to maintain an interface between the skin and the probe for
signal transmission. Use only a coupling gel made for ultrasonic applications.
Using the Probe

Parks’ pencil probes are positioned differently than other Doppler probes because they are designed to
detect blood flow in vessels that are too deep to feel. The main energy of the beam is only as wide as the
crystals in the probe, so you must always search the area of the vessel and tilt the probe to obtain best
Doppler sounds. Parks recommends that you practice searching for arteries at the ankle
1. Inspect the probe for cleanliness and damage prior to each use (See Electrical Safety).
2. Invert the gel squeeze bottle and shake it downward to get the gel near the bottle opening.
3. Squeeze about ¼ inch of gel onto the tip of the probe or skin surface, making sure there are no air
bubbles.
4. Turn the volume control all the way down (counterclockwise).
5. Turn the instrument on, setting the control knob to the frequency of the probe.
6. For normal operation, turn the cautery suppressor off.
7. Gradually turn up the volume (clockwise).
A rumbling sound can be caused by the vibration of the gel from operator movement.
Positioning the Pencil Probe*

1. Place the pencil probe over the approximate position of the target vessel. Probe crystals
▪ Align the probe’s crystals parallel to the vessel for best artery-vein Blood vessel gel
separation.
2. Tilt the back of the pencil probe to an angle about 15 degrees from
perpendicular, making certain there is gel in the pathway between the
probe and the skin.
3. Move the probe and the skin to try to find the center
of the vessel.
▪ Search for the most “pulsating” sound by adjusting
the angle and direction of the probe on the skin. Probe
▪ The Doppler sound for an artery is a hissing noise Gel

at systole.
Listen for best signal
▪ Background sounds are more or less continuous. Skin Line
▪ If you do not hear any sounds, move probe to a

different location.
▪ Note that too much pressure on the skin can
occlude a vein, less likely an artery.
Flow Direction Blood Vessel
*See Diagnostic Procedures section for placement of precordial probe and flat probe.

4. Turn the volume up to near maximum to search for deep arteries, small or obstructed arteries, and
veins.
▪ The Doppler sounds associated with low-velocity blood flow have a very low pitch.
▪ The higher volume setting will also increase the transient background noise.
5. Avoid unnecessary movement of the probe on the skin to minimize transient background noise.
Using the Cautery Suppressor

To Minimize Cautery Interference:
1. Keep probe wires as far away from the cautery wires as possible.
2. Make sure that the patient is well grounded with the cautery machine’s grounding plate.
3. Do not hang the Doppler by its handle on an IV pole; hang it with nonconductive material.
Setting the Cautery Suppressor Level

1. Position the probe to obtain the best flow sound from the patient.
2. After the patient is anesthetized and before the cautery is used, gradually turn up the cautery
suppressor level until the patient’s blood flow sounds start cutting out on peak sounds.
3. Turn the control down (counterclockwise) until the sounds are again normal.
4. If the patient’s flow varies, you may need to make this adjustment again.
Shutting Down the Instrument

1. Turn the instrument off.
2. Wipe the gel off of the probe with a soft tissue.
▪ Disconnect the probe from the Doppler only if necessary for cleaning; probe jacks wear out with
repeated connecting/disconnecting of the probes.
3. Connect the instrument to the battery charger.
Charging the Battery

The 915-BL comes with a 24VDC 0.63 A battery charger. The instrument should be connected to the
battery charger after the last usage of each day.
1. Plug the connector of the battery charger into the battery charger jack on the front of the instrument.
2. Plug the charger into an AC outlet (use appropriate plug adapter for outlets other than 120 V).
The charger indicator lamp will light up to show that the Doppler battery is being charged.
The 915-BL has two battery-charging safety features:
1. The Doppler cannot be operated while the battery is being charged. The battery is disconnected
from the unit while it is being charged; only the charging circuit is active.
2. The battery cannot be overcharged.
A blinking battery indicator lamp warns that the battery needs to be charged. The unit will continue to
operate for a few hours if necessary after the light begins to flash, but should be recharged as soon as
possible. Allow 12 hours to completely recharge the battery. Letting the battery completely discharge
shortens the life of the battery.
Charging Doppler in the Optional Carrying Case

If your Doppler came in a carrying case, Parks recommends that you keep the unit on charge with the
carrying case lid off. The carrying case has slip hinges that allow for easy removal of the lid.
If you do not remove the lid during charging, be sure the charger cord is in the small rubber grommeted
half-moon cutout before closing the lid of the carrying case. This will prevent damage to the charger cord
which might lead to electrical shock.

Performing Diagnostic Procedures
Follow the attending physician’s and the institution’s protocols for diagnostic procedures.
This section of the manual is provided only as a guide, not to determine how a diagnosis is made.
The low-frequency precordial probe may be used to detect the passage of air emboli in the heart. The
high-frequency pencil probe is used for systolic pressures at sites where a stethoscope is not used, as
well as to detect blood pressures that are too low for a stethoscope to auscultate. This probe can also
be used to listen for blood flow and pulses distal to arterial repair. A built-in cautery suppressor with a
controllable threshold shuts off the sound when the interference gets too high.
Detecting the Passage of Air Emboli in the Heart

The cautery suppressor setting must be sensitive enough to detect air bubbles. It is recommended that
placement and settings be tested with an air bubble.
Positioning the Precordial Probe

The active side of the probe is the side that clearly shows the gray disc with
the stripe across the center. This side goes against the chest. You must
use ultrasonic gel over the crystal part of the probe in contact with the skin.
Placement of the probe is critical in order to provide a pathway for the beam
to be transmitted and then detected after it is reflected. Ultrasound does
not pass through bone, so the probe must be centered between the ribs.
Recommended placement is in the 4th-5th intercostal space or over the tricuspid valve.
Placement in the right intercostal space between the fourth and fifth ribs:
1. Place the patient in a supine position.
2. Place the probe so that the central division of the crystals is centered in the intercostal space,
parallel to the ribs. Centering the first few inches of the probe cable in the intercostal space and
taping it in place improves alignment.
3. Verify probe placement by listening for venous flow or passage of air embolus.
4. Affix the probe in place with an adhesive or elastic bandage.
5. Have the patient sit up.
6. Retest the probe to verify probe placement.
If satisfactory placement cannot be obtained using the intercostal space, place the probe over the
tricuspid valve.
Placement over the tricuspid valve:
Follow steps as above, listening for the best swishing blood flow and valve leaflet movement over the
tricuspid valve to optimize placement. Do not turn the cautery suppressor control up so high that it
blocks bubble noise.
Watch for gel loss during an operation, since loss of the interface between the skin and the probe will
impair ultrasonic transmission.
Taking Blood Pressure (BP) Measurements

A Doppler can be used to make accurate systolic pressure measurements, with greater sensitivity than a
stethoscope. A stethoscope is only used to take arm blood pressure, but a Doppler can be used for both
upper and lower extremity blood pressures. The Doppler allows for the detection of low blood pressure in legs,
fingers, and in animal legs and tails. Measurements as low as 10 mm Hg have been documented.Diastolic
pressure can only be estimated, not accurately measured, by Doppler use. To estimate diastolic pressure,
insert the flat probe under the lower edge of the BP cuff and listen for either the loss of sound as diastolic
pressure passes or the return of the dicrotic notch, which is the beginning of the cardiac cycle.

Measuring Systolic Pressure
Because the sound quality is not as critical, it is possible to align the pencil probe’s crystals perpendicular
to the vessels to take blood pressures. Follow the operating instructions for positioning the pencil probe
to optimize Doppler sounds.
Accurate systolic measurements require a BP cuff width suitable to the limb Probe crystals
being tested. The cuff is inflated 20-30 mm Hg above estimated systolic Blood vessel gel
pressure and then released, just as with BP measurements using a stetho-
scope. The systolic pressure is the sphygmomanometer reading when the
Doppler detects the first flow sound as the cuff is deflated.
Patients with calcified vessels resulting from diabetic or renal disease processes can have falsely
elevated blood pressures.
Lower Extremity Arterial Evaluation

Peripheral arterial Doppler studies can give an indication of the severity and location of arterial disease and
monitor its course. Generalized Doppler studies may not differentiate between a stenosis and an occlusion.
Ankle/Brachial Index (ABI)

When a full lower extremity study is not needed, bilateral brachial and ankle blood pressures (BP) can
be taken. The values are used to calculate the ankle/brachial index (ABI), also known as the ankle/arm
pressure index (API). The interpretation of the indices varies, but the normal ratio is ≈ 1.
To Obtain Ankle/Brachial Indices:

1. Obtain bilateral arm blood pressures of brachial or radial artery with the Doppler, using the standard
pencil probe.
2. Place a BP cuff on the right ankle; using a Doppler, listen for a signal on the posterior tibial and
dorsalis pedis arteries (see drawing).
3. Inflate the BP cuff 20-30 mm Hg beyond the last detectable Doppler signal (target 20-30 mm Hg
above higher brachial pressure), and then gradually decrease the pressure in the cuff until you hear
a Doppler signal. This is the ankle pressure. Use result from artery which gives the higher reading.
4. Repeat this procedure for the left ankle.

5. If pressure measurements must be repeated, allow a rest time of about a minute between inflations
of the BP cuff.
6. Divide the ankle pressures by the highest brachial pressure; this is the ankle/brachial index.
7. Example: R L
Brachial systolic pressure 125 140 Higher brachial pressure
Ankle systolic pressure 90 85 is used for calculations.
Ankle/brachial indices (ABI) 0.64 0.61
If the ABI is unquestionably normal bilaterally, there is no need to perform segmental studies.

Lower Extremity Segmental Systolic Pressures
Doppler segmental pressures can locate the general area of an occlusion or stenosis, and indicate the
severity of the disease. Radically different pressures between sites can isolate the region of an obstruc-
tion. Significantly different pressures at the same site on opposite legs can signal an obstruction proximal
to the site in the leg with the lower pressure.
Segmental pressures require the use of blood pressure cuffs sized for the area of the limb to be tested.
This test should be performed on a supine patient after at least 20 minutes rest. Bilateral systolic
pressures are obtained at these sites:
Popliteal Artery
1. Arm, using highest brachial (or radial) artery reading, if ankle/brachial indices are indicated.
2. Ankle, using the doralis pedis or posterior tibial artery, whichever gives the higher reading.
3. Below knee (BK) or calf, using the doralis pedis or posterior tibial artery, whichever gives the higher
reading.
4. Above knee (AK), using popliteal artery if readings are difficult to obtain with dorsalis pedis or
posterior tibial artery.
5. High thigh (HT), using popliteal artery if readings are difficult to obtain with dorsalis pedis or
posterior tibial artery.
Lower Extremity Segmental Pressures After Exercise

Doppler segmental pressures are measured after standardized exercise reproduces a patient’s ischemic
symptoms. The post-exercise (stress) drop in pressures can be diagnostic. Immediately after exercise,
the systolic pressure is taken in both ankles and then in the arm that had the greatest brachial systolic
pressure. If one leg is more symptomatic, the pressure should first be measured in that ankle before
measuring the contralateral ankle. The length of time required to recover resting pressures is also noted.
Lower Extremity Segmental Pressures After Reactive Hyperemia

If exercise is not an option for the patient, reactive hyperemia can be induced. Thigh cuffs are inflated
20-30 mm Hg above the highest brachial pressure for 3-5 minutes and then released. Systolic pressures
are measured as with the exercise regimen. This procedure may be contraindicated because of the level
of discomfort associated with it.

Preoperative and Postoperative Blood Pressure (BP) Measurements
The Doppler is used to monitor blood pressures before and after lower extremity vascular surgery.
1. Measure and record systolic pressure at both ankles immediately prior to surgery.
2. When the blood flow is restored in the treated leg, measure both blood pressures again.
▪ The pressure of the treated leg should be higher than that of the non-treated leg.
▪ Reactive hyperemia following surgery may result in equal or lower pressure of the affected leg on
rare occasions, but the leg will be warm to the touch.
▪ Blood pressure measurements provide an objective evaluation of the surgery. Some surgeons
use the pencil probe (or optional microtip probe) directly on the artery (with sterile jelly for
coupling) just distal to the repair. Critical evaluation of the flow sound detects problems which can
be corrected during surgery.
3. Follow up after surgery by measuring pressures and obtaining ankle/brachial indices.
Upper Extremity Arterial Evaluation

The optional flat probe can be used to make repeated systolic pressure measurements in the radial artery.
Positioning the Flat Probe

1. Position the flat probe over the radial artery with the cord lying across the hand; this will orient the
crystals to point cephalad (antegrade).
2. Use a Velcro strap or tape to hold the probe in place, and anchor the cord at least one place distal
to the probe.
Upper Extremity Segmental Systolic Pressures

Doppler segmental pressures are taken with an appropriately-sized cuff aligned so the bladder is directly
over the artery being measured. Bilateral systolic pressures are obtained at these sites:
1. Upper arm, using the brachial artery.
2. Forearm, using the radial or ulnar arteries.
The differences in pressure readings between extremities and between the sites on each arm can be
diagnostic for a stenosis or an occlusion.
Venous Evaluation
Venous Doppler testing is the most subjective test done in the vascular laboratory. To provide consistent,
reproducible results, the technologist must be thoroughly familiar with venous anatomy (including
deviations from normal) and the subtleties of venous Doppler signals.
Veins are located by first finding the artery, and then moving the probe slightly to either side of the arterial
signal until the characteristic windstorm-like sound of venous flow is heard.
Doppler studies can be used to assess patients for the presence of occlusions, deep vein thrombosis
(DVT), and valvular incompetence associated with varicose veins. Doppler studies can detect
spontaneous venous flow, which is phasic with respiration, and augmentation with distal compression.
See standard textbooks for more information.

References
The following is a partial listing of standard textbooks which provide more detailed information about the
use of Doppler technology to diagnose vascular disease:
Ali F. Aburahma, John J. Bergan, Editors. Noninvasive Vascular Diagnosis: A Practical Guide to Therapy.
Springer; 2006
C. Rumwell, M. McPharlin. Vascular Technology: An Illustrated Review. Davies Publishing; 2003
Noninvasive Diagnosis of Vascular Disease. Davies, Inc; 1999

Maintenance and Service
Cleaning the Instrument
Clean the outside of the instrument as needed. First turn off the power and unplug the battery charger.
Remove dust with a soft cloth or small paint brush. Wash with a soft cloth dampened in a mild solution
of detergent and water. Never use abrasive cleaners. To disinfect surface, use a soft cloth dampened
with liquid disinfectant or use a surface germicidal cloth. After cleaning/germicidal agent dries, remove
any residue with a soft cloth dampened with water. Never let the inside of the instrument get wet.
Cleaning the Probes

1. Remove the gel with a soft tissue after each probe use.
2. Wash any dried gel off the probe with running water. DO NOT scrape off dried gel to avoid
damaging the coating over the crystals.
3. User may opt to wipe probe with alcohol, surface germicidal cloth, or liquid disinfectant; rinse probe
with warm water to remove any residue after cleaning/germicidal agent dries. Do not use bleach.
Do Not Autoclave the Probes

Temperatures above 57.2 degrees Celsius (135 degrees Fahrenheit) destroy the crystal activity and
cause the covering over the individual cables and the outer sheath to shrink and crack. With a raised
temperature, a severe loss of sensitivity will occur. Autoclaving will void the probe warranty.
Tuning
The Doppler unit is tuned by the manufacturer to match the frequency of the probe, and the tuning of
the circuit is very stable. If sensitivity problems are suspected, do not attempt to adjust the instrument;
contact your sales representative or Parks Medical Electronics, Inc.
Routine Maintenance
The Doppler unit does not require regularly scheduled maintenance. The battery may need to be
replaced every two or three years. The probe jacks can wear out with extended use.
To Check the Battery:
1. Determine how long, at most, the Doppler is kept on continuously.
2. Recharge the battery for at least 8 hours.
3. Connect a dry probe to the unit, turn the unit on, and turn the volume 2/3 of the way up.
4. After one hour or twice the longest period of continuous use, whichever is greater, check the
battery indicator lamp. If the lamp is blinking, replace the battery.
To Check the Probe Jacks:
1. Bend back the four sections of the ground flange of the plug of a defunct probe.
2. Insert the center pin of the plug into each probe jack.
3. If there is no friction or resistance, replace the probe jack.
4. If you do not have a defunct probe, contact technical support.

Replacing the Battery
This device uses a 12V, 1.2 Ah sealed lead acid rechargeable battery for its power source. Replace with
Parks Part # 854-0017-01.
Caution: Replace only with the same size sealed lead-acid rechargeable battery. The use of a larger
battery could cause the terminals to come in contact with the circuit board or metal case. Never allow
battery terminals to come into contact with any metal part of the instrument. This could result in fire or
internal damage to the instrument.
To Replace the Battery: 1. Position battery with

positive terminal next
1. Be sure the instrument is turned off to front panel, so both
and the charger is disconnected. wire leads reach
battery terminals.
2. Open the case by removing the four 3. Use single
corner screws. 2. Center and attach strip of tape
battery 1/8” from for padding.
3. Carefully remove circuit board edge of circuit Attach tape to
assembly from the case. board with two battery, but do
1/8” strips of two not remove top
4. Locate the battery and note how the layered double plaid covering.
battery wires are connected. sided tape.
5. For safety reasons, disconnect the

7. Follow the instructions in the accompanying illustration to
black battery wire first and then the
position and secure the new battery.
red wire. Wiggle and gently pull the
connectors, being careful not to break 8. Gently reconnect the red wire first and then the black wire.
the insulation or short to ground. Caution: Failure to match wire and terminal colors will
do permanent damage to the instrument.
6. The battery is mounted to the panel
with adhesive. Gently pry or cut the 9. Carefully replace the circuit board assembly in the case.
battery loose. 10. Replace the four corner screws.
Replacing the Fuse

If the Doppler will not turn on (see Trouble Shooting Guide 1.1), and replacing the battery does not solve
the problem, the fuse may need to be replaced.
To Replace the Fuse:

1. Be sure the instrument is turned off.
2. Open the case by removing the four corner screws.
3. Carefully remove the circuit board assembly.
4. Refer to F1 on the Parts Location Diagram to find
the location of the fuse, or see accompanying
photo.
5. Replace with a 1 A FAST fuse, Parks part #865-
6001-00.
6. Carefully replace the circuit board assembly in the
case.
7. Replace the four corner screws.
Technical Support and Service

If following the troubleshooting guide does not correct the problems you are experiencing with the
Doppler, call technical support at Parks Medical Electronics, Inc.
Should this Doppler require technical service, Parks recommends that the instrument be returned to the
factory. Parks will ensure that electrical components meet the company’s standard of performance.

Troubleshooting Guide
This table lists common problems and suggestions for troubleshooting them. If a problem persists after
these actions have been taken, contact Parks Medical Electronics, Inc.
Problem Situation Suggested Actions
1.0 Doppler unit 1.1 The power control • Disconnect the battery charger
doesn’t turn on knob is on but the battery • Replace fuse (See Maintenance)
indicator lamp does not light • Replace battery if > 3 years old
up (See Maintenance)
1.2 The power control Listen with headphones
knob is on and the battery If there is sound with the headphones but not the
indicator lamp lights up speakers, go to 3.2.1
2.0 Battery is not 2.1 Battery CHARGER Replace the battery charger
charging lamp does not light up when
See Specifications and Replacement Parts
Doppler is turned off and
charger is connected
2.2 Battery CHARGER lamp See Routine Maintenance
lights up when connected to
Replace the battery
charger with Doppler off.
Battery INDICATOR lamp See Specifications and Replacement Parts
blinks with Doppler on
and charger disconnected
after charging for at least 8
hours.
3.0 Hard to hear 3.1 Too much noise 3.1.1 Prevent feedback (screeching sound):
blood sounds (poor • Keep the probe against the skin once gel is
signal : noise ratio) applied.
• Keep the probe out of line with the sound
waves from the speaker.
• Keep probe cable from looping around and
touching itself.
3.1.2 Check for a noisy circuit:
1. Disconnect the probe and turn the Doppler unit
on.
2. Turn the volume all the way up.
3. You should hear smooth white noise or hissing
like the noise of wind or surf.
It may be loud, but it must be smooth.
4. If you hear crackling or sputtering, the circuit is
noisy. Call technical support.
3.1.3 Check for a microphonic circuit:

1. Tap or drum on panel and case with your
fingers. You should hear a dull thud.
2. If you hear a ringing noise, the circuit may be
microphonic. This makes it prone to scream
whenever there is gel on the probe. Call
technical support.

(continued) (continued)
3.0 Hard to hear 3.1 Too much noise 3.1.4 Check for noisy probe:
blood sounds (poor 1. Clean and dry the crystal end of the probe.
signal: noise ratio) 2. Connect the dry probe to the Doppler unit, turn
the Doppler unit on, and turn the volume up.
3. Wiggle the probe plugs.
If you hear a crackling sound, the connection
is noisy.
4. Clean and tighten the probe plugs:
• Wipe the pin in the center of the plug and
the flange around it with contact cleaner or
isopropyl alcohol.
• Squeeze the flange with your fingers (or
gently with pliers). Make the flange form
a smaller circle so that it grips the jacks on
the Doppler panel more tightly.
5. Check for noise again.
6. If there is still noise, bend the cable here:
Send the cable back to the factory for new

plugs if the noise originates here.
7. Flex the cable near the crystals. If the cable
is noisy near the transducer, it cannot be
repaired. Replace probe.
8. Press gently on each crystal with your fingernail.
If a crackling or popping sound occurs, the
probe cannot be repaired. Replace probe.
3.1.5 Check for electromagnetic interference:

Noise that is probably caused by an
electromagnetic field:
• a tone or whistle that does not change pitch
• a buzz or a hum
• a noise like a radio station
• a ticking sound that seems periodic
Confirmation criteria:
• The noise worsens when the probe is held or
applied to the patient.
• The noise disappears when the Doppler unit is
used at another site
• Possibly if the noise lessens when the probe is
disconnected

(continued) (continued) (continued)
3.0 Hard to hear 3.1 Too much noise 3.1.5 Check for electromagnetic interference
blood sounds (poor Identify and eliminate the source:
signal: noise ratio) 1. If the noise is a buzz or hum, the ballast
in fluorescent lights, motors, and battery
chargers are suspect.
2. Try turning off lights and unplugging nearby
devices. Circuitry in cell phones and laptop
computers can cause interference even
when turned off.
3.2 Weak signal 3.2.1 No sound or very little sound:

• If battery indicator lamp is blinking, see 2.2
• Check headphone/speaker connection:
1. Listen for sound with headphones. Then
unplug the headphones and listen for sound
from the speaker. If there is sound in the
headphones, but not in the speaker with the
headphones unplugged, the inside of the
headphone jack is probably bent.
2. Unplug the headphones.
3. Remove the four screws on the outside
corners of the front panel and gently remove
the Doppler unit from the case.
4. Turn the volume control all the way up and
squeeze the contacts on the inside of the
headphone jack.
5. If you hear bursts of sound from the speaker,
bend the contacts to restore the connection.
3.2.2 The speaker is loud, but flow sounds are weak:

• Check the frequency shown above the jack and
the probe frequency to be certain they are the
same. If not, obtain probe of matching frequency.
• If you have another Parks Doppler unit of the
same frequency and a probe that works with it,
try the suspect probe on the good Doppler unit
and the good probe on the suspect Doppler unit.
• If the probe is suspect, replace the probe.
• If the Doppler unit is suspect, call technical
support.
• Probes fail more often than Doppler units. If you
do not have extra equipment to check against,
order a new probe.
• If replacing the probe does not solve the
problem, contact technical support.

Specifications
Bar Code Label Bar code contains information about your Doppler
Serial Number Part Number
Description Date of Manufacture
When requesting service or parts, please have this information available.
Battery 12 V, 1.2 Ah sealed lead acid rechargeable battery.

Fully charged at 14.5 V, needs charging at ≈ 11.3 V, fails at ≈ 10 V.
Battery Charger Domestic Units: Output: 24VDC 0.63A.

or
International Units: Output: 24VDC 0.625A,
with international socket adaptors for ac outlets.
Carrying Case with Lid Aluminum case with handle, removable lid, and space for accessories.
(Optional)
Cautery Suppressor Controllable threshold cuts out excessive cautery noise.
Fuse 1 A FAST fuse.
Gel 0.25 Liter Ultrasound Transmission Gel.
Headphones Optional low impedance stereo headphones override internal speaker.
Internal Speaker Speaker disconnects when headphones are plugged in.
Parks 915-BL UN Manual Operating manual with maintenance and service section.
Probes
Precordial Probe: Low-frequency specified 2.1-2.25 MHz; double-shielded cable; 3/4 in
diameter circular crystal; 5 ft standard cable length.
Standard Pencil Probe: High-frequency specified 8.0-9.9 MHz; 3/8 in diameter; 5 ft standard
OR cable length.
Adult Flat Probe: High-frequency specified 8.0-9.9 MHz; crystals transmit 3/8 in
beam width at 15 degrees from perpendicular; 5 ft standard cable length.
Environmental Conditions for Transport and Storage
Ambient Temperature: -40° C to 70° C
Relative Humidity: 10% to 100%, including condensation
Atmospheric Pressure: 500 hPa to 1060 hPa
Operating Conditions
Ambient Temperature: 10° C to 40° C
Relative Humidity: 30% to 75%
Atmospheric Pressure: 700 hPa to 1060 hPa
IPXO Rating: Degree of protection against ingress of water... none provided.
Size And Weight

Length: 7.875 in
Width: 5.35 in
Depth: 3.15 in
Weight: 2.95 lb

Physiological Effects of Ultrasound
Ultrasound Instrument Console and Transducer Assembly
The biological effects of ultrasound on tissue appear to be threshold effects, contrary to what is assumed
for X-ray. When tissue is repeatedly exposed to ultrasound, with rest intervals in between, there will likely
be no cumulative biological effect. If a certain threshold has been passed, biological effects may occur.
A temperature rise from 37º C to 41º C is permissible for extended periods, whereas a temperature rise
to 45º C may not be acceptable.
Acoustic output power test information is in the Appendix of this manual.
Implanted Devices
Implanted devices such as cardiac pacemakers should be avoided due to the possibility of affecting
their operation. Some plastics used in replacement surgery may be affected by absorption of ultrasonic
energy.
Studies Near Sensitive Tissues

Extreme care should be taken when treating areas near any sensitive nervous tissue. Extreme care
should be taken when treating areas near the eye because of the risk of damage to the retina.
Environmental Hazards
Battery and Instrument
Batteries must be recycled or disposed of according to your local ordinances.
Do not dispose of old instruments or lead acid batteries in land fills.
Ultrasound Coupling Gel

There are no potential environmental hazards from the gels recommended for use with the probes.
Radio Interference
This instrument is intended for use by health care professionals only. This instrument may cause
radio interference or may disrupt the operation of nearby equipment. It may be necessary to take
precautionary measures, such as reorienting or relocating equipment, or shielding the location.
This Doppler may experience a high pitched tone or buzzing noise from radio interference caused by a
cell phone, mobile service, neon sign, an electrocautery, fluorescent lighting, or another Doppler.
Warranty
Parks Medical Electronics, Inc. warrants this Doppler against defects in materials and workmanship
for a period of one year, probes for six months. Parks will, at its discretion, replace or repair free of
charge, including labor, all parts which prove to be defective and subject to such warranty.
This warranty does not apply to any instrument or probe not used according to instructions or
damaged by abuse, accident, alteration, misuse, and/or tampering.

Electrical Safety
CAUTION!
This instrument is intended for use by health care professionals only.
Follow the operating manual instructions for the use of this equipment.
Misuse of this equipment and inappropriate electrical connections can create a shock hazard.
What may appear to be a simple connection to other equipment can put the patient and/or the
operator at risk of electrical shock.
The following is a guide to avoiding common potential hazards. It is not comprehensive. Always seek
the advice of a qualified bioengineer before making any electrical connections.
1. Use caution when connecting the Doppler to other equipment.
Connecting the Doppler to a computer, amplifier or intercom system can be extremely hazardous.
There is a shock hazard unless a medical grade isolation transformer is used. The combined
equipment must comply with medical systems standard 60601-1-1 for the safety of the patient
and the operator. Have a qualified technician or bioengineer review and approve any proposed
connections.
2. Operate this instrument only with the prescribed battery as the power source.
3. This device cannot be used while connected to a charger.
The battery charging circuits in this Doppler have been designed to prevent operation while the
battery charger is connected to provide protection from electric shock.
4. Do not rewire or modify the battery charging circuitry in this Doppler.
The battery charger must comply with the relevant national requirements:
EN60601-1:1990 +A1:1993+A2:1995.
The battery charging input circuitry must not be modified or altered in the field.
Changing this safety feature would compromise safety and violate 21 CFR 898.12.
5. Do not use this instrument in the presence of flammable gas or high oxygen
concentrations.
6. Do not position this instrument so that it comes in contact with metal
surfaces, cautery, or other electronic equipment during use.
Burns can occur through the probe if the Doppler’s metal case is inadvertently grounded when
the electrocautery back plate is not connected properly. To protect against this, ensure that the
cautery instrument’s ground plate is on, and only suspend the Doppler from an insulator if it is
hung on an IV pole.
7. Inspect the probe covering for damage before each use.
Before using the probe, inspect for any cracks or breaks in the protective epoxy covering.
Damage that could allow for ingress of conductive fluids, such as acoustical coupling gel, can
create a shock or burn hazard if the Doppler’s metal case is grounded and comes in contact with
or is used with other electronic equipment.
8. This instrument should not be used with a defibrillator.
Parks assumes no responsibility for the misuse of this equipment.

Ordering Information and Replacement Parts
Ultrasound Transmission Gel
0.25 L, Parks part #748-0003-00
1.0 L, Parks part #748-0001-00
Battery Parks part #854-0017-01
Battery Charger Specify either a charger for domestic use or one for international use.
Domestic Units: 24VDC 0.63A, Parks part #984-0022-00R
International Units: 24VDC 0.625A, Parks part #984-0020-00R
with socket adaptors for ac outlets.
Carrying Case With Lid 800, Parks part #798-0016-02
901, Parks part #798-0018-05
Fuse 1 A FAST, Parks part #865-6001-00
Headphones Optional low impedance stereo headphones with 1/4 in. plug.
Available from Parks Medical Electronics, Inc.
Parks 915-BL, UN Manual Parks part # 050-915B-L0

Probes The probe must match the tuned frequency of the Doppler
Specify frequency (MHz) when ordering
Precordial Probe 19 mm (3/4 in) diameter with double shielded cable.
All probes below are available with double shielded cable.

Standard Pencil Probe: 9.5 mm (3/8 in) diameter
Skinny Pencil Probe 6.35 mm (1/4 in) diameter
Adult Flat Probe: 15.9 mm (5/8 in) x 19 mm (3/4 in)
Infant Flat Probe 12.7 mm (1/2 in) x 15.9 mm (5/8 in)
Replacement Probe Cable lengths (specify)
Standard Cable Length: 1.5 m (5 ft)
Optional Cable Length: 2.1 m (7 ft)
Optional Cable Length: 3.0 m (10 ft)
When ordering replacement parts, refer to the Instrument Information Section of this manual, where user
recorded the specifics about the Doppler.
Contact Information
Parks Medical Electronics, Inc.
Address
Mailing Address: PO Box 5669 Aloha OR 97006-0669 USA
Shipping Address: 19460 SW Shaw St Aloha OR 97007-1242 USA
Phone/Fax
Phone: 503-649-7007 1-800-547-6427
Fax: 503-591-9753
Web
e-mail: Info@parksmed.com
Web Site: www.parksmed.com

Appendix
Acoustical Output Power
For
US Doppler Products
Parks’ products do not have adjustable output power. Our products are offered over the
frequency ranges of 3.9 - 5.3 MHz (low frequency), and 8.0 MHz - 9.9 MHz (high
frequency). The power output increases with frequency due to the design of the
ultrasound transmitter. Parks uses the same transmitter circuit design for all Doppler
products; therefore, this report applies to all of them.
To insure that the acoustical output power evaluation would show the absolute worse
case acoustical output parameters, Parks had the test done using a model 811-B tuned to
9.8 MHz. The output power was 75 mW, which translated to a maximum P of 20.8 mW
for the probe tuned to the unit. This exhibits an optimal coupling efficiency of 27% for
the crystal transducer.
ONDA report T-4PME02 shows that the maximum global output power was 675.3 mW.
The maximum allowed by the FDA is 720 mW. Parks Medical Electronics, Inc. is
exempt from acoustical output labeling for the US market. Parks has decided to provide
the output power for each probe type even though it is not required.
Acoustic Output Table Track 1, auto scanning mode:

Parks Medical Electronics, Inc. offers several different choices of probes:
Pencil
Skinny Pencil
Adult Flat
Infant Flat
Parks provides the maximum values for each probe model.
Uncertainties for Acoustic Output Table Track 1, auto scanning mode:

Intensity Values ±19.30%
Pressure Values ± 9.65%
Mechanical Index ± 9.65%
Power ±19.30%
Frequency ± 2.00%
The uncertainties listed above and in the following tables are from a test report done by
Onda Labs for Parks’ Medical Electronics, Inc. The test report number is T-5PME01.

Appendix

Appendix

Appendix

Appendix

Diagnosis and Treatment of Chronic Arterial
Insufficiency of the Lower Extremities
MODEL 811-B
H OWARD C. B ARON , M.D., Howard C. Baron, M.D. F.A.C.S.*
F.A.C.S.*
Leg distress⎯ cramps, fatigue, or just vague foot, in the heel area, or in the region of the and the superficial veins in the distal portion
pain⎯ often signal the presence of a peripheral metatarsophalangeal joint. The patient of the foot will fill in 10-15 seconds. If arterial
vascular disease. It could be arterial ⎯ the describes the pain as a severe ache or throbbing insufficiency is marked, the normal color may
first sign of arteriosclerosis obliterans. Simple which often wakes him after several hours of take 40-60 seconds to return; in severe cases
office evaluation, including the patient’s sleep. Relief is sometimes obtained by rubbing more than 2 minutes. Reactionary rubor of the
description of leg pain, and an examination of the affected foot or placing it in a dependent foot (a burgundy red color) may occur after the
the affected limbs, will often give a clear picture position over the edge of the bed. Elevating limb becomes dependent; this indicates the
of the underlying vascular problem⎯ where the limb often increases the pain. In some presence of advanced limb ischemia and often
it is, how extensive it is, which vessels are patients, relief is afforded by sleeping in a portends ulceration and “ gangrene of the foot.”
involved, and how adequate is the collateral chair with the leg in a dependent position. An absent or greatly diminished pulse is a
circulation. Leg pain and even “pseudoclaudication,” a diagnostic finding of major importance. The
A typical patient with arteriosclerosis form of leg pain that can mimic true presence of a pulse, however, does not always
obliterans, the most common of the arterial intermittent claudication, can occur with a indicate a normal arterial flow; its absence is
occlusive diseases, develops pain in one or variety of processes other than arteriosclerosis far more significant.
both legs that requires him to stop and rest obliterans such as degenerative disorders, In a patient who complains of intermittent
after walking a short distance. He may call it for example, osteoarthritis of the hip or claudication and has palpable resting pulses,
a cramp, a charley horse, or it may be just a spondylolysis. Compression of the cauda don’t discard the diagnosis of arteriosclerosis
feeling of tiredness in the limb after walking a equina also can produce claudication-like obliterans without investigating the
certain distance. An elderly patient often symptoms. In these patients, the typical cycle “disappearing pulse” phenomenon. Have the
admits to having calf pain for months or of exercise-pain-rest-relief is not present. patient exercise until he experiences
sometimes years with “no reason to mention The presence of normal pulses in the leg claudication; examination of the ankle pulses
it since aches and pains are bound to occur as and a normal ankle systolic blood pressure may then reveal an absent pulse associated
you grow older.” However, where he aids in distinguishing the pain of with leg pallor. The physiologic explanation
pseudoclaudication from arteriosclerosis is simple: exercise causes a marked dilation of
previously could walk 4-5 blocks before the
obliterans. the arteriolar beds within the exercising
calf pain occurred and made him stop, he’s
Examination of the affected foot yields a muscles. During exercise blood is shunted to
concerned because the pain now occurs after
great deal of information. Skin color, texture, these muscle groups causing a drop in the ankle
walking only a block or so.
and consistency all depend on arterial blood systolic blood pressure which is distal to the
Arterial occlusive disease due to
flow and can indicate the presence of an site of the arterial block. As the ankle systolic
arteriosclerosis obliterans, is insidious in onset
impaired circulation. blood pressure falls, the distal pulses
and often present in a patient for many years disappear.
If the patient has only mild, generally
before any ischernic symptoms occur. Rarely Except when life expectancy or surgical risk
asymptornatic occlusive arterial disease, the
will anyone complain of intermittent contravenes due to other systemic diseases,
color and nutrition of the leg and foot appears
claudication, the most commonest symptom angiography and surgical revascularization is
normal. As the ischemic process becomes
of arterial occlusive disease, while indoors. indicated for all patients with symptomatic
more severe, the skin appears shiny and
However, walking outdoors causes the pain arteriosclerosis obliterans exhibiting cutaneous
smooth, and hair is often absent from the toes
to occur. There is a typical pattern to this skin changes, such as ischernic ulcers or
and the dorsal region of the foot. Muscle
symptom of limb ischemia: exercise⎯ pain gangrene; the presence of rest pain or
atrophy, loss of subcuataneous fat, and pallor
⎯ rest⎯ relief. intermittent claudication that handicaps the
all indicate a severe degree of ischernia.
Patients characterize the pain of intermittent patient economically or socially.
A fairly simple and accurate clinical test that
claudication in various ways. One will Angiography is necessary to evaluate the
can measure the degree of arterial insufficiency
describe it as a sensation of cramping or extent of the arterial lesion. Typical arterial
in the affected leg is the elevation-dependency
tightness, “as if the leg is in a vise”. Another maneuver performed while the patient is on lesions due to arteriosclerosis obliterans are
will describe increasing fatigue, eventually the examining table. With the patient lying on segmental, occurring in areas of branching,
forcing the patient to stop walking and rest. his back, place his heels in the palms of your narrowing, or bifurcation sites of an artery.
However, in all of these patients, resting for a hands and elevate both legs 24-36 inches off The commonest occurring at the bifurcation
few minutes is sufficient to relieve the pain. the table. Hold the legs in this position for at of the aorta, or the iliac and femoral artery
If the need to sit down or elevate the extremity least 45-60 seconds. Observe the color of the divisions. Another frequent site is the distal
is a feature of a patient’s complaint, or if it feet and legs, particularly the soles of the feet. superficial femoral artery as it emerges from
takes more than a few minutes for the pain to If the arterial circulation is normal the skin the adductor canal of Hunter and the distal
abate, suspect a disease process other than coloration will decrease only slightly. Skin pallor popliteal artery as it branches into the anterior
arterial insufficiency as the cause of the pain. will develop in the affected limb according to and posterior tibial and peroneal arteries.
As the disease progresses, a different type the degree of arterial insufficiency. If pallor Certain patients are not candidates for
of pain occurs in the toes or heel. Termed rest occurs in both feet, suspect either an angiography; these include the elderly patient
pain or night pain, it is an ominous symptom arteriosclerotic block in the abdominal portion with moderate disability and associated cardiac
of advanced arterial occlusive disease due to of the aorta or similar blocks in the major limb disease, and generally any patient with the
multisegmental blocks in the major limb arteries. After the period of leg elevation, presence of another life-threatening disease. A
arteries and an inadequate collateral generally no more than several minutes, have satisfactory angiographic study provides a
circulation around these blocks. This pain the patient immediately stand up. In a patient visual study of the anatomic lesion, indicating
characteristically occurs in the distal portion with normal arterial circulation in the legs, color the extent of the lesion and to a degree its
of the foot, the toes, over the dorsum of the will return to the foot in 10 seconds or less, severity.
The angiogram, however, does not yield claudication. However, minor ischemic
information regarding the hemodynamic ulcerations may heal and rest pain may
significance of the lesion. For this information occasionally be relieved following
the Doppler flow detector is a useful and sympathectomy.
accurate instrument. The importance of the A limited number of patients with advanced
ankle/arm systolic blood pressure ratio in the arteriosclerosis obliterans may show
diagnosis and objective assessment of arterial improvement over periods of weeks from
disease underscores the value of the Doppler nonsurgical measures including rest, the use of
ultrasound blood flow detector. Although the vasodilators, and avoidance of tobacco smoking,
auscultatory method with a stethoscope is permitting the development of an additional
one of the most common blood pressure collateral circulation. However, the long period
measurements in clinical medicine, it is seldom before results can be evaluated is risky:
used in the lower exremity because it is gangrene may supervene, calling for emergency
difficult to obtain the Korotkoff sounds in surgical reconstruction of the occluded
the distal portion of a limb, especially when vascular bed if amputation is to be avoided.
arterial occlusive disease is present. The
Doppler flow detector, when used with a
sphygmomanometer and a pneumatic occlusion
cuff, can measure the lower extremity systolic
blood pressure easily and accurately.
Normally, the ankle systolic blood pressure is
slightly higher than the arm systolic blood
pressure. Any pressure gradient or difference CONCLUSION
that exists between the arm and ankle systolic There are both humanitarian, economic and
blood pressure provides a valuable, objective social reasons for mounting a strong effort to
hemodynamic assessment of the arterial lesion. salvage the lower limbs in patients, who are
Certainly, the lower the ankle systolic blood often elderly, and debilitated, but obvious
pressure when compared to that in the arm, candidates for a revascularization procedure.
the greater the gradient and therefore, the more The physical, psychological and economic
advanced the arterial occlusive lesion in the burdens following amputation preclude a useful
distal abdominal aorta or lower extremity or comfortable life in the years remaining to
arteries. them.
Two of the most important aspects of Limb salvage, the desideraturn of any age, is
managing patients with Arteriosclerosis particularly important in the geriatric patient
obliterans are the need to avoid any form of whose care then places a heavy burden on a
injury to the affected foot; this includes the spouse of similar age or another family member.
avoidance of any form of home surgery on the A patient confined to a wheelchair or bed is
feet, and the avoidance of tobacco smoking. A unable to attend to even the simplest personal
recent study of ours indicates that 40 percent needs; he often becomes withdrawn from
of major lower extremity amputations might human contacts, psychologically as well as
have been avoided by taking simple physically damaged.
precautions against infections stemming Partial limb revascularization, by saving the
from mechanical, thermal, or chemical extremely valuable knee joint, is often a
injuries to the feet. Meticulous, periodic reasonable alternative, allowing salvage of as
podiatric care is necessary for any foot with much as possible of a limb affected by end-stage
an impaired circulation with its known ischernia.
increased susceptibility to infection. Even The goal should be treatment of the disease
fungal infections such as athlete’s foot can put without loss of the lower limb or, if amputation
the ischernic foot at serious risk. Certain becomes necessary, a below-knee procedure or
over-the-counter pharmaceutical preparations even a transmetatarsal amputation, permitting
for removing corns and calluses that contain the patient to lead a more normal life.
caustic chemicals can be harmful to 222 East 19th Street
surrounding tissues, especially when used in New York, New York 10003
the presence of an impaired circulation and
should be avoided!
Thromboendarterectomy of the occluded
artery or the use of bypass grafts are the
operative procedures most frequently used for
revasculatization of the ischernic limb.
*Attending Vascular Surgeon, Cabrini Medical Center, New
Sympathectomy may be helpful in certain York, N.Y.; Associate Professor of Surgery, New York,
patients, but is is rarely considered for patients University School of Medicine, New York, N.Y.
who are candidates for arterial surgery and it is
not recommended for treatment of intermittent
Practical Office Technics for
Physiologic Vascular Testing*
COL CLYDE 0. HAGOOD, JR., MC, USAF, LTC DAVID J.
MOZERSKY, MC, USAF, and SSGT RANDAL N. TUMBLIN, BS, USAF, †
Lackland AFB, Tex
Abstract: The development of the Doppler ultrasonic flow velocity detector

has improved diagnostic accuracy in peripheral arterial occlusive disease.
Survey of the peripheral vessels with the Doppler ultrasonic flow velocity
detector, measurement of systolic arterial blood pressure at the ankle and
arm, and exercise testing are three easily done tests which may be readily
carried out in the doctor’s office and which provide useful
information. Noninvasive vascular testing should be in the
armamentarium of all primary care physicians.
A therosclerosis of the peripheral vessels is Material and Technics

extremely common in our society and is The Doppler ultrasonic velocity detector has
responsible for significant morbidity and become a familiar tool used by obstetricians
mortality. It is therefore imperative that the and vascular surgeons alike.5 The instrument
physician who first encounters patients with uses two piezoelectric crystals. One crystal, when
vascular complaints recognizes the disease and stimulated by an electric voltage, emits a
begins proper treatment. Until recently, the continuous wave of ultrasonic energy at a
diagnosis of arteriosclerosis obliterans has been frequency of 5 to 10 MHz, which is transmitted
dependent upon the clinical history and physical through the skin. If this sound wave is reflected
examination. As a result, the disease has only back from stationary tissue interfaces, the
been detectable in a relatively far advanced stage. frequency of the returned signal received by the
Since the introduction of the Doppler ultrasonic second crystal will be the same as the transmitted
velocity detector in 1959, more sensitive and frequency. If the sound wave strikes moving
objective methods of evaluation have been red cells, the returned signal will be a different
available to the clinician.1-4 The use of these frequency from the transmitted signal. The
technics, however, has been restricted to a difference is directly proportional to the velocity
relatively small number of specialists and of the blood, according to the Doppler principle.
investigators. Although they are extremely simple The transmitted and received frequencies are
to do, these examinations have not been widely compared electronically and the difference
used by primary care physicians. between the two, the Doppler shift frequency, is
The purpose of this paper is to familiarize amplified. Since this frequency is in the
clinicians with three simple office technics for a u d i b l e r a n g e , it can be perceived with
detecting atherosclerotic occlusive disease and earphones or a loudspeaker. For most clinical
to present three cases that illustrate the purposes, the audible signal is all that is
efficiency of these technics. necessary. Ultrasonic energy transmitted by
these instruments has been tested both in the
*Read before the Section on Surgery, Southern Medical Association, laboratory and clinically and has been found to
Sixty-seventh Annual Scientific Meeting, San Antonio, Tex.
†From the Department of Surgery, Vascular Surgery Service, Wilford be non-destructive to tissue. 6 Examination can
H a l l U S A F M e d i c a l C e n t e r, L a c k l a n d A i r F o r c e B a s e , Tex .
Reprint requests to CMR #8, Box 369501, Lackland AFB, thus be carried out at frequent intervals without
Tex 78236 (Dr. Hagood).
fear of over-exposure.
SOUTHERN MEDICAL JOURNAL, Vol 68, No. 1 17

OFFICE TECHNICS FOR VASCULAR TESTING - Hagood et al
After the routine history and physical examination in the nature of the arterial signal can be
have been completed, the peripheral vessels are detected easily,5 after gaining some experience
surveyed with the Doppler ultrasonic velocity with the instrument.
detector. The quality of the arterial signals is An objective and reproducible determination of
evaluated at the common femoral, superficial the extent of the occlusive disease process can
femoral, popliteal posterior tibial, and dorsalis be made by measuring the systolic arterial
pedis arteries bilaterally. If the vessels are patent, pressure at the ankle. 7 Standard blood pressure
these signals will be composed of at least two, cuffs are placed around the ankle and the arterial
and often three, distinct sounds. The first is flow signal is monitored in the posterior tibial or
high-pitched and is distinctly separated from the dorsalis pedis artery (Fig 2). The cuff is then
second (Fig 1, A). inflated until the arterial signal is no longer
When mild proximal arterial stenosis is present, detected. With the probe still in place, the
there is a slight decrease in the frequency of the pressure is gradually lowered in the cuff until
first sound and the second sound is no longer flow signals are audible once again. The point at
detected (Fig 1, B). As the degree of occlusion which flow is re-established is the systolic
becomes progressively more severe and pressure at the level of the cuff. Under normal
collateralization develops, the signal becomes circumstances, the systolic pressure in the ankle
more monotonous with only small fluctuations should be equal to or above the systolic pressure
with each heart beat (Fig 1, C). These changes in the brachial artery. If the artery is occluded,
FIG I
NORMAL SCALE - 2 cm = 1 SEC. OBSTRUCTED
Graphic representation of audible Doppler ultrasonic flow velocity signals obtained from the posterior tibial artery of three
separate patients. A - normal; B - obstructed; C - severely obstructed.
18 SOUTHERN MEDICAL JOURNAL, Vol 68, No. 1

FIG 2
Technic of obtaining ankle systolic blood pressure. The angle of the probe in relation to the long axis of the posterior tibial
artery should be optimized to obtain the best signal.
the pressure will be lowered in the vessels distal immediately after the activity, using the method
to the occlusion. An arm-to-ankle pressure gradient previously described. The form of exercise which
of more than 20 to 30 mm Hg is suggestive of is selected will depend upon the interest,
occlusion at more than one level. It has been requirements, and resources of the physician. In
found that the ankle/arm pressure ratio correlates our clinic, all patients have been exercised on a
well with the severity of the obstructive process. 4 level, motorized treadmill at 3 mph to the point of
When the ratio is one or greater, it is unlikely that claudication, or a distance of 1,000 yards. This is
significant obstruction is present. Similarly, rest an indication of how far the subject can walk at a
pain is rare when the ankle/arm pressure ratio is marching pace on flat ground and is an objective
greater than 0.5. assessment of his complaints of claudication.
There are some patients in whom the ankle pressure Strandness and Bell 3 have found that by angling
is normal or nearly normal and who h a v e the treadmill at 12% grade and at a speed of 2
significant complaints of claudication. In these mph the amount of work involved is increased and
patients, exercise testing is an extremely valuable pressure gradients are accentuated. Normal
method of evaluation.8 subjects can walk five minutes with no difficulty
When the blood flow to a limb is increased by and no drop in ankle pressure. A patient propelled
exercise, the pressure gradient between the arm and treadmill may also be used with a metronome. The
ankle is accentuated. 2 In severe cases of obstructive patient is instructed to step each time the
vascular disease, the ankle systolic pressure may be metronome beats and, in this inexpensive way, the
unobtainable following exercise. Depending upon functional and provocative test of the patient’s
the extent and location of the disease and the type exercise capacity can be carried out.
of exercise, there may be a period of up to 20 to 30
minutes before the ankle pressure returns to normal Tw o l e s s e l a b o r a t e m e t h o d s o f e x e r c i s i n g
levels. The routine vascular examination should patients are available and may be used in office
include stressing the patient with some form of practice. Carter 8 has recently used active plantar
exercise and measuring the arm and ankle pressure and dorsiflexion of the foot against a
SOUTHERN MEDICAL JOURNAL, Vol 68, No. 1 19

resistance provided by the attendant’s hand. Alternatively, Doppler survey and ankle pressure measurements not
the patient can be instructed to rapidly perform toe lifts only suggested the correct diagnosis preoperatively,
until fatigue or calf pain develops. These methods are but also confirmed the salutory effect of the surgical
less standardized than treadmill exercise, but they have procedure post-operatively. Patients with symptoms
the advantage of requiring no special equipment. suggestive of claudication and intact pulses may be
If the initial ankle systolic pressure after exercise is equal mistakenly treated for arthritis, neuritis, or emotional
to or higher than pre-exercise values, then the test is problems. As was shown in this case, the correct
normal and no further measurements are required. If the diagnosis can be quickly and accurately made, using
initial ankle pressure is low, the measurements are repeated simple testing procedures.
every minute for the next ten minutes. It should be Case 2. A 62-year-old man with many complicated
emphasized that the Doppler survey, a nkl e pre ssure medical problems came to our clinic with complaints
measurements, and exercise testing can be done in less of pain in the right calf and night pain. Pain in the
than 20 minutes by paramedical office personnel. calf was precipitated by walking less than 100 ft and
The following cases are presented to illustrate the relieved by rest. Physical examination of the right
usefulness of vascular testing methods in the clinical leg showed a normal pulse in the groin. No other
situation. pulses were palpable. The right brachial systolic blood
pressure was 206 mm. Hg. The right ankle systolic
Case Reports pressure was 78 turn Hg. Survey with the Doppler
C a s e 1 . A 5 2 - y e a r- o l d m a n c a m e t o t h e m e d i cal ultrasonic velocity detector showed a slightly abnormal
clinic complaining of pain involving the right leg, thigh, flow signal high in the right groin. This signal became
and buttock. The pain was precipitated by walking one high-pitched and continuous at a point about two inches
block and relieved by rest. Physical examination of below the inguinal ligament, and low-pitched,
the right leg showed 2+ femoral and dorsalis pedis pulses monotonous signals were noticed distal to that level.
and a weakly palpable posterior tibial pulse. No trophic He walked for 108 yards on the flat treadmill at 3
changes or temperature differences between the two legs mph. There was a 66.5% decrease in ankle systolic
were observed. It was the physician’s initial impression pressure after exercise. An arteriogram done by the
that the slightly diminished pulses probably were not Seldinger technic showed minimal decrease in the aorta
responsible for the symptoms, but the patient was and the right iliac artery. The superficial femoral artery
referred to the vascular surgery c l i n i c f o r f u r t h e r was occluded in Hunter’s canal. Close inspection of the
s t u d i e s a t t h a t t i m e . T h e s u r v e y with the Doppler bifurcation of the common femoral artery suggested
ultrasonic velocity detector revealed abnormal signals significant occlusive disease, involving the origin of the
at the right femoral, popliteal, dorsalis pedis, and deep femoral artery.
posterior tibial areas. The brachial systolic pressure was Due to the patient’s poor state of general health, the
112 turn Hg. The right ankle systolic pressure was 86 right groin was explored under local anesthesia. A large
mm. Hg. The patient was able to walk 115 yards at 3 occlusive plaque was located in the common femoral
mph on the treadmill. artery and a tight stenosis of the deep femoral orifice
These studies suggested the presence of severe occlusive was observed. A common femoral and deep femoral
atherosclerosis of the right iliac artery. Angiography endarterectomy were done. The patient was examined
confirmed a high-grade stenosis of the e n t i r e r i g h t in the laboratory three months after operation.
common iliac artery and its bifurcation. An aortoiliac Brachial systolic pressure was 132 mm. Hg. The right
endarterectomy was done subsequently. Postoperatively ankle systolic pressure was 70 mm. Hg. He walked 1,000
the patient was completely asymptomatic. Survey with y a r d s o n t h e f l a t t r e a d m i l l a t 3 m p h w i t h a 61%
the ultrasonic velocity detector showed normal flow in decrease in ankle pressure after exercise.
both lower extremities. The brachial systolic pressure Comment. The history and physical findings were not
was 140 mm Hg. The ankle systolic pressures were 137 compatible with an isolated, superficial femoral artery
turn Hg on the right and 140 mm Hg on the left. obstruction. Disabling claudication and night pain are
Comment. At the time the patient was initially seen in usually indicative of multiple arterial occlusions. The
the general medicine clinic, his complaints were 128 mm Hg pressure gradient between the arm and
suggestive of severe occlusive arterial disease. The fact ankle suggested that this was the case. Since a full
that pulses were palpable in all areas, however, was femoral pulse was palpated, and only a slightly abnormal
confusing to the physicians who first saw him. When he Doppler flow signal was heard in the upper common
was examined in the vascular laboratory using the femoral artery, it was thought that the o b s t r u c t e d
Doppler ultrasonic velocity detector the lesion was arteries were located in the thigh or calf or both.
quickly localized to the right iliac artery. The 34 The presence of arterial signals in the popliteal artery
turn Hg arm/ankle gradient demonstrated the severity indicated its patency. Doppler examination of the
of the problem, and the functional disability was dorsalis pedis and posterior tibial arteries showed arterial
confirmed by his performance on the treadmill. Since the flow signals similar to those obtained in the popliteal
patient’s job required a great deal of walking he was artery. This suggested no significant obstructive lesion
essentially disabled by his condition. On the basis of between these levels. On the basis of these findings,
the objective tests, proper, diagnosis and treatment t h e o b s t r u c t i v e l e s i o n s could be localized to the
were begun. superficial and deep femoral arteries.
20 SOUTHERN MEDICAL JOURNAL,Vol 68, No. 1

FIG 3 Conclusions
Palpation of pulses and inspection of the limb are
subjective methods of evaluating complaints that
may be related to arterial insufficiency. Since the
physician whose practice includes patients with
many varying problems may feel insecure about
his ability to evaluate pulses, objective testing
methods have a real place in the diagnostic
armamentarium. The Doppler ultrasonic velocity
detector may be thought of in the same manner as
one thinks of a stethoscope, as an instrument
which extends clinical perception. It is a rapid
and safe tool which can provide relevant, and at
times indispensable, information.
Measurement of ankle systolic pressure by the
Doppler ultrasonic technic has proven to be an
objective and repeatable test which correlates well
Angiogram showing a large plaque in the common femoral with the anatomic situation. Exercise testing
artery involving the orifice of the profunda. provides both a functional assessment of the
patient’s complaints and a diagnostic challenge by
Results of angiography confirmed the superficial femoral which small, resting pressure gradients can be
artery obstruction and suggested severe stenosis of the deep accentuated. Resting pressure measurement,
femoral orifice (Fig 3). Since the hemodynamically
exercise testing, and Doppler ultrasonic survey are
significant lesions were confined to the thigh, it seemed
logical to increase the collateral circulation distal to extremely simple methods of evaluation by which
the occluded superficial femoral artery. Therefore, even minor degrees of occlusive arterial disease
an endarterectomy of the distal common femoral may be detected. The equipment necessary to
artery and deep femoral artery orifice was done. evaluate vascular problems can be purchased for
It is significant to note that there were no changes less than $1,000.
in the patient’s physical examination after operation
and, without vascular testing, only his testimony could
be used to indicate a beneficial result. The preopera-
tive ankle/arm ratio was 0.38. After operation, it
r o s e t o 0 . 5 3 . I n a d d i t i o n , t h e p a t i e n t ’s e x e r c i s e
tolerance increased nearly tenfold. These concrete
data should be used as the criteria for success or
failure.
C a s e 3 . A 5 4 - y e a r- o l d d e n t i s t w a s s e e n o n e y e a r
after bypass graft for severe aortoiliac occlusive
disease. Three months after operation, he was References
evaluated in the laboratory. Brachial systolic pressure 1 . Satomura S: Ultrasonic blood rheograph. J Acoust Soc
was 108 mm Hg. Ankle systolic pressures were 114 Japan 15:151-154
m m H g o n t h e r i g h t a n d 111 m m H g o n t h e l e f t . 2 . Winsor T, Hyman C, Payne JH: Exercise and limb circulation
Both ankle pressures increased after exercise. There in health and disease. Arch Surg 78:184-192
3 . Strandness DE Jr, Bell JW: An evaluation of the hemo-
were no signs or symptoms of ischemia. He was dynamic response of the claudicating extremity to exercise.
studied again eight m o n t h s l a t e r. H i s p u l s e s w e r e Surg Gynecol Obstet 119:1237-1242
intact. The arm pressure was 114 min Hg, and the 4 . Yao ST, Hobbs IT, Irvine WT: Ankle systolic pressure
measurements for arterial disease affecting the lower
ankle pressures were 126 mm Hg on the right and 96 extremities. Br J Surg 56:676-679
mm Hg on the left. He walked 1000 yards on the flat 5 . Strandness DE Jr, Schultz RD, Sumner DS, et al: UItrasonic
treadmill at 3 mph with no symptoms. There was a flow detection: a useful technique in the evaluation of
peripheral vascular disease. Am J Surg 113:311-320.
24% decrease in the left ankle pressure after exercise.
6 . Wi l d J J , R e i d J M : E f f e c t o f u l t r a s o u n d o n biological
Comment. This patient, though asymptomatic, is tissues. J Acoust Soc Am 25:270-280
exhibiting disease progression, which will require closer 7. Strandness DE Jr: Management of Arterial Occlusive
Disease. Chicago, Year Book Publishers, Inc.
follow-tip. This disease progression could not have 8 . Carter SA: Response of ankle systolic pressure to leg
been detected on a clinical basis, but was readily exercise in mild or questionable arterial disease.
detectable using simple vascular testing technics. N Engl J Med 287:578-582
SOUTHERN MEDICAL JOURNAL,Vol 68, No. 1 21

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PARKS

915-BL Dual-Frequency Doppler

Read this manual prior to use.

915-BL, UNM 5.5 6/2012 915-BL Dual Frequency Doppler 1

Introduction Maintenance and Service

915-BL Dual Frequency Doppler 3

Place this instrument on a clean, nonconductive, level surface.

TYPE B APPLIED PART

Instrument Identification Information

Serial Number Part Number

Model Date of Manufacture

Date instrument purchased Customer Number

4 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

915-BL Dual Frequency Doppler 5

Probes with double-shielded

Standard Pencil Probe Precordial Probe

6 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

915-BL Dual Frequency Doppler 7

Using the Coupling Gel

Using the Probe

Positioning the Pencil Probe*

▪ The Doppler sound for an artery is a hissing noise Gel

▪ If you do not hear any sounds, move probe to a

8 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

Using the Cautery Suppressor

Setting the Cautery Suppressor Level

Shutting Down the Instrument

Charging the Battery

Charging Doppler in the Optional Carrying Case

915-BL Dual Frequency Doppler 9

Detecting the Passage of Air Emboli in the Heart

Positioning the Precordial Probe

Taking Blood Pressure (BP) Measurements

10 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

Lower Extremity Arterial Evaluation

Ankle/Brachial Index (ABI)

To Obtain Ankle/Brachial Indices:

4. Repeat this procedure for the left ankle.

915-BL Dual Frequency Doppler 11

Lower Extremity Segmental Pressures After Exercise

Lower Extremity Segmental Pressures After Reactive Hyperemia

12 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

Upper Extremity Arterial Evaluation

Positioning the Flat Probe

Upper Extremity Segmental Systolic Pressures

915-BL Dual Frequency Doppler 13

14 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

Cleaning the Probes

Do Not Autoclave the Probes

915-BL Dual Frequency Doppler 15

To Replace the Battery: 1. Position battery with

5. For safety reasons, disconnect the

Replacing the Fuse

To Replace the Fuse:

Technical Support and Service

16 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

3.1.3 Check for a microphonic circuit:

915-BL Dual Frequency Doppler 17

Send the cable back to the factory for new

3.1.5 Check for electromagnetic interference:

18 Parks Medical Electronics, Inc. Aloha, Oregon U.S.A.

3.2 Weak signal 3.2.1 No sound or very little sound:

3.2.2 The speaker is loud, but flow sounds are weak: