Background

ALiEM Cards are the current iteration of Dr. Michelle Lin’s Paucis Verbis Cards. They began as Michelle’s pocket notes, containing details she wanted to access quickly. But by sharing them freely on the internet, they have grown to be a trusted point-of-care reference for Emergency Medicine providers worldwide.

The heart and soul of these cards is there in the original name: paucis - few, verbis - words. That focus on concise, high-yield information, turned the cards into an ideal reference for a busy emergency department or a quick end-of-shift teaching session. Experienced attendings and new medical students alike, utilize the cards, albeit in different ways.

The ALiEM Cards project has several goals:

1. Expand the breadth and depth of their content
2. Keep existing cards current with new literature and practice standards
3. Optimize accessibility to the cards with emerging technologies
4. Rapidly iterate to meet users’ evolving needs
5. Academically detail this iteration as a model for design-thinking driven development in medical education

This guide sets the basic writing and design standards for the ALiEM Cards. It is meant to ensure uniformity in style and formatting of the cards, among a multitude of authors.

Brevity & Completeness

Authors and editors must strive for brevity and completeness.

Brevity ensures the cards’ utility as a point-of-care, or just-in-time, reference. Completeness means the cards can be trusted to contain the critical information needed to make immediate, point-of-care medical decisions.

Card Topics

The art of the ALiEM Card is in selecting the topic. Some information is too basic. Some too esoteric. There is a sweet spot. Search for it.

Good topics have some of the following characteristics:

• Relevant to Emergency Medicine or Urgent Care. This is self-explanatory.
• Provides a succinct answer to a concrete question. Example: does my patient need corticosteroids for Bell's Palsy?
• Not a controversial topic. Cards should focus on topics for which there is broad-based consensus.
• Esoteric information that one need not memorize, but lookup when needed. Example: PESI Score for Pulmonary Embolism. This is a long complex score with many exclusion criteria. It need not be memorized but accessed quickly when needed.
• Evidence-based data on common ED complaints. Example: Does Your Dyspneic Patient Have CHF. This card provides a quick summary of a comprehensive review that can aid in clinical decision making at the bedside.
• Brief, yet complete, summaries or checklists of core EM content. Ideally the card can be read in less than 5 minutes on shift. Example: Anaphylaxis. This card includes information well-known by experienced ED physicians, yet is an excellent bedside teaching tool, quick reference to check for new developments, and a complete reference with many details expected of a textbook, but in concise, scannable chunks.
• Summaries of topics that are not needed daily, and may only be part of the user’s peripheral knowledge. Example: Ankle Fractures: Lauge-Hansen Classification, a card that details the specifics of an injury ED providers encounter regularly. Reviewing prior to calling an orthopedic consult may be beneficial.
• Content should be based on current data and recommendations.

This list is far from exhaustive. Use these suggestions to help choose your topic.

Card Content

Cards should be based on reliable reference material.

Journals of high caliber should be used. Within Emergency Medicine these might include Annals of Emergency Medicine, Journal of Emergency Medicine, Academic Emergency Medicine*, Resuscitation,* or other similar publications.

Textbooks such as Tintinalli's Emergency Medicine and Rosen’s Emergency Medicine are also reliable sources. Similar caliber texts, even from other specialities, are acceptable.

Cards should be based on the most up-to-date standards.

The ALiEM Cards should reflect the most current trends and practice. Yet they should still be based on solid evidence. A small 15 patient study with compelling results should not be the basis for a card; a robust RCT from a well-respected journal should. High-quality systemic reviews and meta-analyses can be a good starting point.

Include a PubMed or Google Scholar search.

While developing your card, consider refining your PubMed or Google Search and including that with your card. This will help future editors keep up to date with new material related to your card.

Bullets vs. Paragraphs

Some point-of-care references focus primarily on scannable, bulleted lists in an effort to maximize brevity. Other references focus primarily on traditional textbook-style prose in an attempt at completeness. ALiEM Cards focus on the user of the reference. Do what maximizes both brevity and completeness.

Bullets should be favored over prose.

The card on Brugada Syndrome is instructive. Just five bulleted items convey the major features of the illness with both brevity and completeness:

Brugada Syndrome

• Genetically linked, cardiac sodium channelopathy
• High risk for sudden death in young, healthy adults because VTach/VFib
• Mean age of sudden death = 41 ± 15 years
• Higher prevalence in males and Asian descent
• Atrial fibrillation associated in 10-20% cases

Prose should be used when it improves clarity and/or brevity

The card on ABG Interpretation illustrates this nicely. Using prose, rather than slavishly formatting the content in a bulleted list keeps this information concise and scannable. Bulleted lists are used within this passage to add clarity.

Look at pH: Whichever side of 7.4 the pH is on, the process that caused it to shift to that side is the primary abnormality

Calculate the anion gap. If AG ≥ 20, there is a primary metabolic acidosis regardless of the pH or serum bicarbonate concentration

Calculate the excess anion gap = total anion gap - 12 + measured bicarb - If sum is > 30, then metabolic alkalosis - If sum is < 23, then nongap metabolic acidosis

Respiratory compensation occurs almost immediately in response to metabolic disorders.

Metabolic compensation occurs over 3-5 days in response to respiratory disorders.

Bulleted lists do not require bullets.

Review the passage from ABG Interpretation above. It is essentially a five item bulleted list. Unlike the Brugada Syndrome passage, these list items are longer and less scannable. One item includes its own sub-list. Not indenting these items with a bullet preserves scannable blocks of text and avoids unnecessary nesting of lists.

Abbreviations

Our readers are mostly from North America, but not all. Be careful about using non-traditional abbreviations for the sake of brevity. Commonly accepted abbreviations include: HIV, AIDS, ECG, CXR. When in doubt, spell out in its first instance with the abbreviation in parentheses. Example: Acute limb ischemia (ALI): limb-threatening emergency

Tables

Simple tables may improve brevity and completeness.

The following table from the card on Aortic Dissection details the presence of various risk factors among patients with known dissection. Tabular layout clearly favors clarity and brevity.

Risk Factor	Incidence
Marfan syndrome	4.9%
Hypertension	72.1%
Atherosclerosis	31%
Known aortic aneurysm	16.1%
Prior aortic dissection	6.4%
Diabetes mellitus	5.1%

Complex tables should be avoided.

Complex tables often complicate interpretation. Tabular data also does not lend itself well to digital distribution where device screen size and orientation vary greatly and proper formatting of the table cannot be guaranteed.

Consider this example from the National Asthma Education and Prevention Program on classifying asthma severity. It has neither brevity nor clarity. It may favor completeness.

Images

Images often add clarity without convolution. Their use is encouraged.

Images should convey information visually.

Images should be used to illustrate what would be complex to explain. This image from the Focused Assessment with Sonography in Trauma is a good example. Be sure to describe the image and define any labels.

Avoid using images to display textual information.

Do not use an image to display complex tabular or flowchart data. Better to reformat that information into plain text.

Consider copyright when selecting images

Images should either be your own, have an appropriate creative commons or other similar license, or be granted permission for use by their copyright holder. Copyright or source citations must be included.

Technical Requirements

Images should be no smaller than 200 x 200 px. and no larger than 640 x 640 px. PNG format is preferred. JPG and GIF are acceptable.

Videos

Video is a new capability of the cards. Consider using video only when text or images are insufficient and a reasonable quality, concise video is available, preferably less than two minutes long, and no longer than five minutes.

Video must be hosted on another platform, such as YouTube or Vimeo, that allows embedding of the clips within the card.

The same copyright considerations apply to video as to images.

Spelling & Grammar

Of course you know spelling and grammar are assumed to be impeccable. Here are some rules to keep things consistent:

Use American English spellings

Our readers are mostly from North America. American English spellings should be used.

Use serial commas

Write bananas, apples, and oranges, rather than bananas, apples and oranges. There is disagreement about which way is preferable. We use the former.

Use only one space after periods, not two.

After all, we no longer use typewriters.

Include units after numbers

We are scientists. Separate the units from the number with a space, eg, 45 mg/dL.

In-Line Citations & Bibliography

In-line citations and bibliographies follow AMA format.

Inline references should be superscript

In-line references are designated by superscript numbers, inserted before the period at the end of the sentence. Example: This is a statement1.

Electronic links must be provided with all references

Links should travel to the paper’s PubMed page, eg, http://www.ncbi.nlm.nih.gov/pubmed/24554447.

If no PubMed link is available, DOI links are an acceptable alternative

Example Journal Citation

Radecki RP, Rezaie SR, Lin M. Annals of Emergency Medicine Journal Club. Global Emergency Medicine Journal Club: Social media responses to the November 2013 Annals of Emergency Medicine Journal Club. Ann Emerg Med. 2014 Apr;63(4):490-4. PMID: 24655449. http://www.ncbi.nlm.nih.gov/pubmed/24655449