4723097 reading xrays for beginners

8/13/2019 4723097 Reading XRays for Beginners

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X-rays, from www.icufaqs.org Mark Hammerschmidt, RN

Its just my opinion, but I think that ICU nurses should have some basic (really basic) idea of howto look at x rays of some of their !tools of the trade"# $% tubes, central lines, &' lines, maybe acouple of others bviously you arent *oin* to be tryin* to compete with physicians in readin*them, but still I think its useful to be able to look at a stat film and say !+ee, it looks like that $%tube is in the ri*ht main stem " r ! ow, no wonder the &' line is stuck in wed*e, look how far init is-" %hin*s like that .o I went out on the web and surfed around, and I found some film ima*esthat may be helpful

's usual# please remember that this material is not meant to be an official reference of any kind /its supposed to reflect the experience and knowled*e of a preceptor as it is passed on to a new01 orientee 'lso please let me know when you find errors or omissions / well put them in ri*htaway

' word about the x ray ima*es# film ima*es can be impenetrably hard to read, even if you have,as radiolo*ists are said to have# x ray vision (2a-) ' lot of these ima*es areclearer on the computer screen, I *uess because the resolution is lots hi*her than whatsproduced by most printers 3ine, anyhow %ry a laser printer, or try lookin* at the pictures on yourmonitor and adjustin* the contrast sometimes it helps

4 hat is an x ray56 hat are some common x ray procedures that my patients may have in the 3ICU57 ho takes x rays58 ho reads them59 hat is a stat film5 2ow stat should stat be5: Can I stay in the room if my patient is bein* x rayed5; hat are those clip thin*s that the x ray techs wear5< It seems like my patient has been x rayed twelve times today / is that safe5= ho was 0oent*en54> Is it true that 3arie Curie *lowed in the dark5

44 hat about &ierre546 hat is a C'% scan5 hat is a spiral C'% scan5 2ow lon* to C% scans take547 hat is a C%'548 hats the difference between a C% scan and an 30I549 hat is an 30'54: hy do some tests use contrast54; hats the connection between I? contrast and renal failure54< hat is this I hear about mucomyst54= @o we *ive contrast in the 3ICU56> hat kind of I? access does my patient have to have to *et I? contrast564 hat about +astro*rafin566 hat is the problem with +lucopha*e (metformin)5

Aist of B ray Ima*es#

a 1ormal chest film with markersb Chest film with a really clear trachea and carinac Chest film with $%% and 1+%d $%% in the ri*ht mainsteme %he same $%% pulled back to proper positionf Chest film with $%%, and C?& line, and maybe an 1+ tube* Chest film with a trach in place, and old sternotomy wire sutures

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h ' non tension pneumothoraxi %ension pneumothorax with a really neat mediastinal shift

j 'nother tension pneumok 'n 1+ tube causin* a pneumothoraxl ' bi* pleural effusionm ' chest film with two chest tubes# ones in position, the other isntn ' &' lineo ' &' line with an interestin* object nearbyp 'n I' & tip (you sure5), and a &' line, probably not in far enou*hD 'n abdominal film with dilated bowel loopsr ne patient, two films, before and after developin* tamponades ho is this, and what happened to him5t %he first ever C?& line

1- What is an x-ray

2eres what I know / I mean, I could look up all sorts of information, but this is supposed tobe what your preceptor knows, ri*ht5 Is your preceptor a medical physicist5 1o- ut can yourpreceptor work an intra aortic balloon pump, a C??2 machine, and a Eoll pacin* box (howabout one at a time, okay5) 2opefully-

.o# x rays are a kind of dan*erous but useful ioniFin* radiation %hey produce ima*es onsilver coated film that lives in the x ray plates that were forever puttin* behind one part of ourpatients or another

%he dan*ers in exposure to x rays are two# how much power they use to shoot, and howclose you are to the shot !%he exposure varies inversely with the sDuare of the distance fromthe source " 3eanin*# that your risk of exposure drops a whole lot when you *et away fromwhere the machine is pointin* at .o stand way back I usually stand behind the tech shootin*the film (*rin-)

!- What are some common x-ray "rocedures that my "atients may ha#e in the M$%&

ur patients *et !ima*ed" a lot 3ost of our ima*es are portables, shot in the bed, althou*hall too often patients will have to travel to the radiolo*y suites for C% or 30I studies .omecommon situations#

!&lain films"#

'fter intubation 'fter the insertion of any central line in the neck or chest, or after repositionin* a

line 'fter the insertion of a chest tube 'fter the insertion of a soft naso*astric tube / in fact, I hear that nowadays

theres a push on to *et a film after the insertion of .alem sump tubes as well,which to me doesnt seem to make sense if youre *ettin* *astric materials fromit, althou*h it mi*ht just be in the distal esopha*usG

henever your patient looks like theyre in worsenin* respiratory distress %o help evaluate !before" and !after" treatment of pulmonary edema @aily to evaluate chan*es in, say, pneumonia, or any other developin* disease

process

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0arely, well have bone fracture films to shoot, but usually fractures in ourpatients are stabiliFed in the most basic way by orthopedics, and then left to beresolved once the more life threatenin* problems are settled

C% scans and 30Is# (startin* from the top and workin* south, and only listin* the onesthat come readily to mind)

2ead # 'ny kind of acute neuro event, or symptoms of a neuro event, will oftenbuy your patient a head C% In C?'s, the critical Duestion is# is it embolic, orhemorrha*ic5

1eck and spine # usually a traumatic neck injury can be !cleared for c spines" withplain films, but now and a*ain youll see a C% or 30I for these $ncephalitis andmenin*itis also show up nicely on C%s, I understand

Chest # lots of reasons for chest scans / traumatic injuries, bleeds, tumors, fluidcollectionsG

'bdomen # also lots of reasons / specific or*an disease, fluid or air collections,

retroperitoneal bleeds (we see our share of these / lots of our patients *et!hardware iFedH in one fem or the other)

&elvis # 'lso for lookin* at retroperitoneal bleeds, I believe / in the 3ICU anyhow.ICU patients mi*ht have an unstable pelvis after a car crash

'- Who takes x-rays

B ray techs shoot all our films %here are specialty techs who run the C% scanners and the30I machines I believe that there is a sin*le tech who does all the portable C% scans @ontfor*et thou*h, that on trips to the scanners you are the person in char*e of the patientclinically If you think theres a problem, or the chance of a problem / speak up- %he techs are

used to this, and are more than willin* to help you *et the patient throu*h the scan safely%heres a detailed !trip to the scanner" section in the !1ew in the ICU" 'J

(- Who reads them

ur house officers do Duick reads on stat films, but if they have any Duestions about whattheyre lookin* at, theres always a radiolo*ist available in the house to help them out 'll thefilms are reviewed on radiolo*y rounds within 68 hours

)- What is a stat fi*m How stat shou*d stat +e

%his can vary a lot, dependin* on how busy the techs are .tat in my mind really ou*ht to bewithin 7> minutes at the most .ometimes it just takes lon*erG

- %an $ stay in the room with the "atient if my "atient is getting x-rayed

I find that I rarely need to / the only time I can think of is if the patient is havin* lateraldecubitus films shot (side lyin* / theyre usually lookin* to see if a collection of fluid movesdownwards with *ravity and !layers out") It can be hard to keep a patient in this position

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when theyre hooked up to lots of hardware / check with the tech you may find yourselfwearin* lead and holdin* the patient up

y all means, use appropriate measures to safely, briefly sedate your patient if she needs itfor the x ray If youre takin* your patient off the floor for C% or an 30I, check with the team /if your patient cant be accurately scanned because of a*itation, theres no point in makin*the trek if you cant safely *ive them sedation to help them hold still

- What are those c*i" things that x-ray techs wear hou*d we wear them

%he techs all wear film dosimeters / *ad*ets that measured their cumulative exposure toradiation over some *iven period of time 's for nurses wearin* them / I need to ask aroundabout this (Update / the techs said no )

/- $t seems *ike my "atient has +een x-rayed twe*#e times today 0 is that safe

Its obviously a Duestion of priorities# will the patient benefit more from havin* the x raystudies, or from not havin* them5 Aookin* around on the web I found an interestin* way oflookin* at the problem# you compare the amount of radiation from the x ray study with theamount of normal !back*round" radiation the patient mi*ht receive just by lyin* still in bed,bombarded by cosmic rays, and radon from the rumpus room in the basement %hey call thisthe ! ack*round $Duivalent 0adiation %ime" / or $0% 2ere are some of the numbers#

@ental x ray# 4 weeks worth of normal back*round radiation Chest film# 4> days Upper +I series# 4 9 years (uh ohG) Aower +I series# 6 years I understand myself that KU s use a lot more radiation than chest films do / I

always stood way back when we were havin* our kidsG

%he website *ivin* this information went on to say that !no studies of radiation to humanshave demonstrated an increase in cancer at the doses used in dia*nostic radiolo*yG" Imobviously not tryin* to do a comprehensive review here / but as far as I went, the informationwas reassurin* Lour mila*e may varyG

- Who was Roentgen

orth mentionin* / he discovered that these stran*e rays *enerated by his vacuum tubecould pass throu*h certain materials, make interestin* ima*es on silver coated photo*raphicplate 1ot knowin* what the rays were or where they came from, he called them !B" like theunknown Duantity in an al*ebra formula

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2ere he is#

%he second picture is of 3rs 0oent*en / part of her, anyway / maybe the first or second x rayever taken

12- $s it true that Marie %urie g*owed in the dark

1eat rumor, huh5 3y dau*hter did a report on 3arie in hi*h school, and says that to this daythey still cant handle her diaries / theyre too radioactive

11- What a+out 3ierre

I have no idea, but my dau*hter says theres an old joke#

&ierre# (*oin* to bed at ni*ht) 3arie, turn the li*hts out3arie# %hey are out, dear

1!- What is a %45 scan What is a s"ira* %45 scan How *ong do scans take

1urses have a pretty *ood idea of what C% scans are / they produce a series of !cuts",ima*es across the body workin* upwards or downwards throu*h the body section inDuestion

.piral C%s are a newer kind of scan / the scannin* tube rotates continuously as the patientmoves alon* throu*h the scanner / the result is better ima*in* with lower radiation exposure3ost scans nowadays take less than half an hour / its transportin* your possibly unstablepatient to the scanner and back that makes for all the stress %heres a full description of how

you mi*ht plan and carry out a trip to the scanner in the !1ew In the ICU" 'J

1'- What is a %54

C%' stands for C% 'n*io*raphy / the idea is to do a spiral C% scan while I? contrast isinjected C%' can apparently reDuire a lot of contrast / 4>> 49> ml %his may be a bad thin*for your patients kidneysGC%' seems to be the scan of choice when evaluatin* &$s andvascular aneurysms of one kind or another

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1)- What is an MR4

30' is !3a*netic 0esonance 'n*io*raphy" / which is to say, 30I lookin* at blood vesselflow, probably usin* contrast 30I studies use a contrast material called !*adolinium" youllhear the techs say thin*s like# ! ith or without *ado5" +adolinium turns out to be an element

/ heres what I could find out about it# !+adolinium, chelated to a carrier molecule, is anintravenously injected 30 contrast a*ent which Gnormally stays in blood vesselsGit has theeffect of makin* vessels, vascular tissues, and areas of blood leaka*e appear bri*hter "(%hanks 0ay 2su, ashin*ton U .chool of 3edicine-) .o this is what youll probably seethem *ive when youre lookin* for a bleed somewhereG !+adolinium is excreted throu*h thekidneys, with a half /life of 4 69 / 4 : hours " +ado has the reputation of bein* very low onthe aller*ic reaction list

1 - Why do some %5 tests use contrast

%hey help li*ht up the structures that youre tryin* to see In C% scannin*, the contrast dye isiodine based / which is why patients with aller*ies to shellfish arent supposed to *et them%hese dyes definitely have dan*ers associated with them# obviously, some people are *oin*to have severe aller*ic reactions %he other problem, and we see this one more often thanwed like to, is the fact that a dye load can really, seriously hurt a patients kidney function,especially if theyve *ot some de*ree of renal failure already 2ere are some of the mainpoints#

I? contrast dye can cause reaction that is about the same anaphylaxis, and is treated thesame way If a patient reacts it has nothin* to do with previous exposure to the dye

0eactions occur in less than 9N of the patients who *et I? contrast dye %heres analternative !low molecular wei*ht" dye that lowers the risk of reaction to less than 4N

2ives is what most people show as a reaction to contrast

%he risk of a fatal reaction is somethin* less than 4 in 4>>,>>>

&retreatment helps 'ntihistamines and corticosteroids, as well as usin* !non ionic, lowmolecular wei*ht" contrast dyes means lower rates of anaphylactoid reactions %hereaction may not be related to previous exposure, but people who have reacted beforemay react a*ain / the rate is 4; :>N 'sthmatics and people with multiple aller*ies are at*reater risk for reaction

.evere reactions are very rareG 4 in :69> exams usin* A3 contrast

1 - What is the connection +etween iodine-+ased contrast and rena* fai*ure

2ere Im *oin* to summariFe one of a really neat series of clinical pearls from the U. 'rmy&harmacy website, edited by 3ajor @ave 'ndersen %his one was comprehensive yetsuccinct, and extremely clear %hanks, 3ajor 'ndersen

' :6 year old patient with diabetic nephropathy is booked for a C% scan with contrast 'll labsare normal except for a *lucose of 479, and a creatinine of 6 8 (Uh ohGIve been in too

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many of these situations myself Can you spell C??25) %he radiolo*ist is concerned about*ivin* contrast to a patient with a creatinine over 6 > Is there anythin* that can prevent orminimiFe further kidney dama*e5

'cute renal failure from I? contrast / this they define as a rise in creatinine of more than > 9within 8< hours after the dose / ran*es from = 8>N in diabetics with mild to moderate renalinsufficiency, to 9> =>N in diabetics with severe chronic renal insufficiency ('ck- I take my*lucopha*e, dont I5 'nd the doc says my feet tin*le because I stand up all ni*htG)

.ome summary points#

Aots of thin*s have been tried # Ca O6 channel blockers, mannitol, lasix, dopamine, others,with little or no success !3annitol and furosemide actually worsened renal function morethan saline alone "

%he problem is that C% scans of many areas are basically worthless without contrast(2ow about *oin* strai*ht to 30I instead5 r is there no advanta*e5)

1on ionic, A3 contrast may cause less kidney dama*e

I? hydration before and after a contrast dose is shown to limit kidney dama*e 1ormal orhalf normal saline at a rate of 4mlMk*Mhour for 46 hours before, and 46 hours after thecontrast seems to be effective

1/- What is this $ hear a+out mucomyst

' recent study (1$P3 6>>> 87# 4 8) showed that a :>>m* dose of 3ucomyst(acetylcysteine) on the day before and the day after the contrast dose si*nificantly loweredthe incidence of contrast induced acute renal failure 'nybody know how this works5

1 - 7o we gi#e contrast in the M$%&

e *ive oral contrast in the form of *astro*rafin %he C% orders have built in dosin* orders totell you what to do / usually its somethin* like ; 9cc of *astro*rafin in 6>>cc of water eitherorally (ack-) or throu*h an 1+ tube, repeated several times Check with the team if youreworried about your patients kidneys

!2- What kind of $8 access does my "atient ha#e to ha#e to get $8 contrast

e take patients with all sorts of I? access to the scanners, but for some reason the techsdown there want the patient to have a plain, *arden variety heplock in one arm or the other

'nybody know why they dont use a central line5 3ake sure the I? is patent, and in a siFablevein / that contrast *ets injected pretty fastG

!1- What a+out 9astrografin

'ppaarently this stuff is very safe to use It is iodine based

!!- What is the "ro+*em with 9*uco"hage :metformin;

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(I took a personal interest in this oneG) +lucopha*e has the rare but unhappy ability ofprovokin* a severe lactic acidosis, especially in renal failure situations If the I? contrast dosewere to push a patient from, maybe, C0I to '0 , then the presence of *lucopha*e in thatsituation would be a bad thin* It appears that the routine is to hold *lucopha*e for a daybefore the exam, and for two days afterwardsG *ood to know

a 1ormal Chest ilm with 3arkers

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2eres thetrachea,nicely at

%he carinaou*ht to bearound here

I was tau*htthat a line is!central" if thetip is insertedbeyond thethird rib Isthis the thirdor fourth,behind theclavicle5

If the C?& tip isthis far down, itneeds to bepulled back tothe .?C

1ot much of abubble.ometimesthey look like abi* clearvolleyball Loucan

decompress abi* stomachbubble with an1+ tube

%hese are the two !hemi"

diaphra*ms .ometimes one or theother is pushed down, or pulled up,for one reason or another

@ont you think that arrows and text boxes are just the most artistic thin* sinceAeonardo5 (3y son showed my how to make them ) Ima*ine what they coulddo for the 3ona Aisa- 2ey, yo, Aouvre, what do you say5


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b Chest film with a really clear trachea and carina

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%his film shows thetrachea, carina, and

main stems veryclearly / theyre notalways so easy tosee

2eres the carina 'n$% tube thats too farin may poke thecarina / this may bewhy your patient ishackin* andchokin all the time

%he ri*ht mainstem is wherepatients oftenaspirate to itQsmore in a strai*htvertical linedownwards thanthe left one $%tubes that areadvanced too faralso usually windup here

%his is a pretty unpleasant lookin* x rayCompare these fluffy lookin* lun* bases to thenice clear ones in the first picture / probablypneumonia .ee how the left hemidiaphra*mhas been pulled upwards5 %hats a pneumoniathin*


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c Chest film with $%% and 1+%

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&retty sure this isthe carina

I may be seein*thin*s, but Im prettysure this is the end ofan $% tube ' little toohi*h, I think

%his looks like the radio opaDueline on a naso*astric tube Itlooks just like the $K+ monitorin*wires, but it has no electrodeconnector at the end, and its inthe typical place

2eres an electrodewire with a connectorat the end


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d $ndotracheal tube in the ri*ht main stem

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.omethin* definitely wron* with this picture @oesthis patient have lun* sounds on the left afterbein* intubated5 1o5 I wonder why her sat is solowG

%his is the

carina I think

2eres the left main stem 'ny air *ettin* intothis lun*5


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e $% tube pulled back to the proper position

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%he web site said that this was the same patient, after the tube had beenrepositioned (pulled back ) Im not sure ut anyhow this persons $% tube isnt ineither main stem, and the left lun* looks nicely aerated (I cant see the carinaeither ) hat kind of central line does this patient have / meanin*, is this in theinternal ju*ular, or the subclavian, or (hey, lets be creative) is it maybe a femoralline5 Is the tip where it ou*ht to be5


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f Chest film with $%%, C?& line, and maybe an 1+ tube

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I have no idea why this ima*e came out reversed, but there are a couple of thin*sfor you to try to find# $% tube look all ri*ht to you5 hat kind of central line doesthis patient have5 %ip position okay5 Is there an 1+ tube5


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* Chest film with a trach in place, and old sternotomy wire sutures

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2eres ashort trach

.ee thesternalwires5.M&C' + orvalve


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h ' non tension pneumothorax

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'll the normalfuFFy stuff here onthe left are whatthey call !vascularmarkin*s"

're there anyvascular markin*shere5 heredthey *o5 hy isthis whole areavery clear5 (%heword is!hyperlucent" /which I believetranslates as !veryclear")


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Aots of vascular markin*son this side

hered the markin*s *o5

%his is definitely a much more dan*erous situation than the one before it %histime, the pressure on the pneumo side has steadily increased, and now the heartis *ettin* shoved forcibly over to the other side / definitely classed as a !bi* badthin*" hich service would you stat pa*e to come see this patient5

$verybody knows how to set up a chest tube, ri*ht5 'nd you all know what an airleak is5 hat maneuver could you make before the sur*eons arrive5

If this patient had an arterial line, you mi*ht see a nice example of !pulsusparadoxus" / blood pressure that drops with inspiration, and rises with expiration

/ in fact, this mi*ht be your first clue that a tension pneumo mi*ht be developin*%ake a look at the !Chest %ubes" 'J for more on this G

i %ensionpneumothoraxwith a really neat

mediastinal shift(I *uess thepatient doesntthink its soneatG)

@oes everybodyknow theprocedure forinsertin* an I?catheter into the

chest todecompress apneumothorax5

here does it*o5 ho puts itin5 2ow far inshould it *o5

hat should youhearR and thenmaybe see thepatient do5 lyaround the roombackwards5


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@efinitely havin*too much fun withthe arrowsG

hy is thishemidiaphra*mbein* pusheddownwards5

'nother really niceima*e from the?irtual 2ospital

1ot a pretty picture,however .ee thepneumothorax downthere at the bottom5

'ctually, is there oneon each side5

.o, uh, did theynever hear thephrase# !.top whenyou feelresistance-"5

j 'nother tension pneumo

k an 1+% causin* apneumo Aooks like a@obhoff


20/25

m ' chest film with two chest tubes# ones in position, the other isnt

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&retty bi*effusion overthere on thepatients ri*ht

hat shouldwe do5

%he break in the line showswhere the suction tube has a

side port hat happens if thetube *ets pulled on, and theport *ets outside the skin5

@oesnt look ri*ht hat noise mi*htyou hear when you *et close to thispatient5 2ow could you use sterilevaseline *auFe to put a temporary fixto this situation5 ho needs to be

l ' bi*pleuraleffusion

Aookin* at the chest tube on the left / see the break in the line that travels alon* the sideof the tube5 %hats where the draina*e port is .uppose that chest tube is hooked up tosuction throu*h a pleurevac box / what mi*ht you hear while standin* close to thepatient5 hat could you do about it as a temporary fix5 hat team would you call if youfound this situation, and what would you have ready for them when they came5


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'wful picture, but youcan see how the &'line curls around as it*oes throu*h the 0',the 0?, and uparound into the &'3y arrow is pointin*to where I think the tipis I think this line isprobably not Duite farenou*h in, and wontwed*e If the &' linewere to slip back, say,to the 0? / how mi*htyou know5 hat

would you do aboutit5

%hats more like where a &' tip ou*ht to be I had to play with the contrast inthis ima*e to make the line a little clearer, so its very dark 'ny *uesses as towhat the white arrow is pointin* at5 hat if I were to tell you that maybe thelaryn*oscope operator was a little hasty durin* intubation5 .hould we call thedentist if the patient codes5

n a &' line

o ' &'line with aninterestin*objectnearby


22/25

p 'n I' & tip (0eally5), and a &' line, probably not in far enou*h

D 'n abdominal film with dilated bowel loops

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%he story herewas that theblack arrow ispointin* at the tipof an intra aorticballoon pump Ithink I see sternalwires, and myarrow I thinkmaybe is pointin*to the reallymisplaced end ofa &' line, but Idont see anyballoon tip

hich doesntmean it isntthereG

e dont spend all our timelookin* at the chest, youknow 2as your patient beenon a fentanyl drip5 +ascollection can cause thebowel to distend for all kindsof reasonsGtime for0e*lan5 r a sur*eon5


23/25

r ne patient, two films, before and after developin* tamponade

2eres a little sample of electrical alternans#

http#MMec*library comMelecSalt html

'nd heres a sample of what pulsus paradoxus looks like on an a line tracin*#

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hat a difference two months makes- et this patient had some rub- %hatllteach you not to for*et your Indocin- %here are three situations where youmi*ht see a clear pulsus paradoxus on your a line wave, and this is one ofthem# pneumothorax, pericardial tamponade, and really severedehydrationMhypovolemia hich one is this5 %he other clue is somethin*you only mi*ht see now on the $K+ monitor# !electrical alternans" / theJ0. complexes are alternately bi*, then small, then bi*, then small %heymay *et a liter (-) out of this patients pericardiumGthats a portacath, ri*ht5
http://ecglibrary.com/elec_alt.htmlhttp://ecglibrary.com/elec_alt.htmlhttp://ecglibrary.com/elec_alt.html


24/25

s ho is this, and what happened to him5

Copyri*ht materials used with permission of theauthor and the University of IowaQs ?irtual 2ospital# www vh or*

%hanks Iowa- (!Is this heaven5", !1o, its ?irtual IowaG")

t %he first ever C?& line

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'ny ideas5 %his turnsout to be the !Iceman" /the poor *uy that wasfound after bein* froFenfor so lon* on that*lacier in .witFerland%he pointed object inthe yellow rin* turns outto be the arrowheadthat killed him I thou*htthe .wiss wereneutralG
http://www.vh.org/http://www.vh.org/http://www.vh.org/


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.ee it there, in white, comin* up the left arm5 %his is apparently the ori*inal famous photo*raphtaken by erner orssmann, back in 4=6= 'pparently in the *rip of enthusiasm, he threaded aurolo*ic catheter upwards into his own arm, then ran downstairs to the x ray room where he *otinto a scuffle with a collea*ue who thou*ht he was *oin* nuts, kicked him in the shins to *et by,and then shot this film %he rest, as they say, is / !2ey, would you just throw in a central linealready5 I cant keep this *uy on peripheral neo forever, yknow-"

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4723097 reading xrays for beginners

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