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Gail Fromes, MS, RN University of Michigan Department of Neurology

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1500 E. Medical Center Drive Ann Arbor, MI, 48109 (734) 936-9010 [email protected]

Education The University of Michigan M.S. 1987 Ann Arbor, Michigan St. Xavier University B.S. 1977 Chicago, Illinois National Certification Certified Neuroscience Registered Nurse American Board of Neuroscience Nursing 1999 - 2004 Professional Experience 1990-Present Clinical Nurse Specialist Comprehensive Epilepsy Program Department of Neurology The University of Michigan Ann Arbor, Michigan Currently providing comprehensive outpatient nursing care to medically refractory epilepsy patients undergoing treatment with medications, surgery, and vagus nerve stimulation (VNS). Responsibilities include following patients in outpatient clinic visits, medication adjustments and monitoring, VNS programming and coordinating VNS program, patient education, coordinating epilepsy surgery evaluations, phone management, and leading the epilepsy support group. www.med.umich.edu./neuro/epilepsy/team.htmwww.med.umich.edu/neuro/epilepsy/vns.htm 1987-1990 Instructor Medical-Surgical Nursing Undergraduate Program School of Nursing The University of Michigan Ann Arbor, Michigan Taught undergraduate nursing students in small groups in the clinical (hospital) setting, lectured on various topics, supervised and taught students in the clinical lab. Wrote exams questions, and participated in planning all aspects of course. Summer, 1987 Staff Nurse Outpatient Clinics Internal Medicine The University of Michigan Ann Arbor, Michigan Provided care to outpatients in a variety of internal medicine clinics and also did phone management and triage of patients.

http://www.med.umich.edu./neuro/epilepsy/team.htm


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1985-1987 Teaching Assistant Medical-Surgical Nursing Undergraduate Program School of Nursing The University of Michigan Ann Arbor, Michigan Taught undergraduate nursing students in small groups in the clinical (hospital) setting, lectured on various topics, supervised and taught students in the clinical lab. 1982-1985 Staff Nurse, Charge Nurse, Neuro I.C.U. Preceptor University Hospital The University of Michigan Ann Arbor, Michigan Provided intensive nursing care to critically ill patients with brain and spinal cord involvement. Managed ICP and hemodynamic monitoring, including cardiac monitoring. Served as charge nurse to staff of 4-5 nurses and precepted new orientees to unit. 1981-1982 Staff Nurse, Preceptor Medical-Surgical I.C.U. Ingalls Memorial Hospital Harvey, Illinois Provided intensive nursing care to critically ill patients with a variety of medical- surgical diagnoses and post –operative management of patients undergoing major surgeries. Experience included hemodynamic monitoring, and cardiac monitoring. 1977-1981 Staff Nurse Medical-Surgical General Care Units Ingalls Memorial Hospital Harvey, Illinois Provided nursing care to patients on orthopedic, and gynecology units. Experience with patients in casts, and in traction, and pre and postoperative care of patients with joint replacements, and pre and postoperative care of women with gynecologic problems. Professional and Academic Memberships American Epilepsy Society www.aesnet.org 1995-Present Epilepsy Foundation of America www.efa.org 1995-Present American Association of Neuroscience Nurses www.aann.org 1992-Present


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Publications (see C.V. for complete list) Articles Marzec, M., Edwards, J., Sagher, O., Fromes, G., and Malow, B.A. (2003). Effects of Vagus Nerve Stimulation on Sleep-related Breathing in Epilepsy Patients. Epilepsia, 44(7), 930-935. Kaur, A., Selwa, L., Fromes, G., and Ross, D.A. (2000). Persistent Headache after Supratentorial Craniotomy. Neurosurgery, 47(3), 633-636. Rivet, S., and Fromes, G. (1991). Nursing care of the patient undergoing long-term monitoring. Horizons, 5(3), 18-19. Fromes, G. (1986). Effect of nursing interventions on intracranial pressure. Nursing Research Review, 2(4), 2. Abstracts Edwards, Jonathan C., Fromes, Gail A., and Sagher, Oren, (2002). Vagus Nerve Stimulation for Refractory Seizures in Developmentally Delayed Adults. Epilepsia, 43(Supplement 7), 339. Fromes, G.A., Edwards, J.C., Holland, K.D., Sagher, O., Garton, H.J.L., and Ross, D.A., (2000). Clinical Utility of On-Demand Magnet Use with Vagus Nerve Stimulation. Epilepsia, 41(Supplement 6), 117. Selwa, L.M., Greenfield, L.J., Fromes, G., Drury, I., Henry, T.R., Passaro, E., and Ross, D.A. (1998). Distinguishing Features of Patients with Refractory Partial Epilepsy Not Offered Resection after Intracranial Monitoring. Epilepsia, 39(Supplement 6), 83. Papers, Workshops, or Poster Presentations (see C.V. for complete list) “Safety and Tolerability of VNS” presented for Registered Nurses and Physician Assistants, VNS Symposium, Las Vegas, Nevada, July 2004 “Innovative Treatments in Neurological Disease: A Nursing Perespective on Vagus Nerve Stimulation”

presented for Nursing Grand Rounds, University of Michigan Hospital, Ann Arbor, Michigan, November 2001.

. “Clinical Utility of On-Demand Magnet Use with Vagus Nerve Stimulation” poster presentation at the American Epilepsy Society meeting, Los Angeles, California, December 2000. “Educating the Epilepsy Patient” Telephone-Conference presented for Nurses, American Epilepsy Society, October 2000. “Epilepsy Nursing for The New Millennium: Vagus Nerve Stimulation” presented for the American Association of Neuroscience Nurses Meeting, New Orleans, Louisiana, March 2000. “Nursing Considerations for the Patient Undergoing Epilepsy Surgery," presented for the


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Twelfth Annual Neuro Critical Care Conference, The Michigan League, The University of Michigan, Ann Arbor, Michigan, March 1994. "Effects of Sex Difference and Hippocampal Lesions on Exploratory Behaviors and Wayfinding

Performance in Rats in a Novel Environment," presented for the Graduate Student Nursing Research Symposium, University of Michigan, Ann Arbor, Michigan, April 1987.

"Intracranial Hypertension: Mechanisms for Care," presented for the Advances in Critical Care Nursing Practice Symposium, Ann Arbor, Michigan, November 1983. Committees, Academic Preceptorships, and Administrative Positions (see C.V. for complete list) Preceptor Nursing 506: Bio-Behavior II 2001 Clinical Practicum School of Nursing Graduate Program The University of Michigan Member Epilepsy Education Committee 1990-1994 Department of Neurology The University of Michigan Member Information Technology Task Force 1989 School of Nursing The University of Michigan

Job Description I would like to continue to work as the clinical nurse specialist of the epilepsy program at UM. Completing my ACNP certification will allow me to be more independent and efficient in my patient care. Five Year Goal Statement As an ACNP, I hope to be able to participate more fully in the epilepsy program at UM. I would like to start my own research projects and with the efficiency that the NP will add to my practice, I may be able to do that. The vagus nerve stimulator, in particular, provides opportunities for research as much remains unknown about specific programming strategies and efficacy in epilepsy. There will be new medical devices for epilepsy in the future and I hope to be involved in the planning and research of those. Summary of ACNP Student Clinical Experiences


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Hope Clinic, Ypsilanti, Michigan This clinic delivers health care to indigent patients. The challenge for nurses is to assess and treat the patient with minimal resources. As an NP student, I was able to assess patients with all types of problems, from abdominal pain to skin cancer. My assessment skills were sharpened and diagnostic skills using as few tests as possible to evaluate the cause of the patient’s problem. Breast Cancer Clinic, University of Michigan, Ann Arbor The patients in this clinic are undergoing various treatments for breast cancer, including experimental protocols. As an NP student, I was able to assess the patients for adverse effects from therapy as well as evaluate coping and emotional responses to breast cancer. The experience included opportunities for providing psychological support as well as medication management and physical assessment. Heart Failure Clinic, St Joseph Mercy Hospital, Ann Arbor, Michigan The patients in this clinic are in various stages of heart failure, NY class 2-4. Many of the patients have pacemakers and/or ICD devices. The experience allowed me to assess heart sounds and perform the BioZ analysis of a patient. This is a non-invasive method to assess cardiac output, systemic vascular resistance, thoracic fluid content, etc. Treatment decisions involving issues of palliation and quality of life were frequent. The opportunity to evaluate lipid profiles in these patients, and manage lipid reducing medications was also provided. Diabetes Clinic, University of Michigan, Ann Arbor, Michigan This clinic delivers care to both Type I and Type II diabetic patients. This experience allowed me to gain expertise in the extensive realm of diabetes education, involving diet, medications, and lifestyle. I was able to provide patients with diabetes education, in clinic and by phone. I received much training in how to assess a patient’s blood glucose levels by reading logs, and advise changes on oral hypoglycemic agents and insulin. I assisted the NP to start group visits for her patients in clinic by doing a literature review, contacting patients, and modifying forms and letters for use in this clinic and proposing tools for evaluation. I helped prepare for, and attended the first session. References Michelle Aebersold, RN, Nursing Supervisor, Neurology Inpatient Unit and Clinic Linda M. Selwa, MD, Interim Director, Epilepsy Program, University of Michigan Jonathan Edwards, MD, Director, VNS Program, University of Michigan

CURRICULUM VITAE GAIL FROMES HOME ADDRESS WORK ADDRESS 400 Wesley Avenue Department of Neurology Ann Arbor, Michigan, 48103 Clinical Neurophysiology Laboratory University of Michigan Hospitals University Hospital 1B300/0036 1500 E. Medical Center Drive Ann Arbor, Michigan, 48109-0036 Telephone: (313) 936-9010 EDUCATION The University of Michigan M.S. 1987 Ann Arbor, Michigan St. Xavier University B.S. 1977 Chicago, Illinois NATIONAL CERTIFICATION Certified Neuroscience Registered Nurse 1999 - 2004 American Board of Neuroscience Nursing PROFESSIONAL EXPERIENCE 1990-Present Clinical Nurse Specialist Epilepsy Program Department of Neurology The University of Michigan Ann Arbor, Michigan 1987-1990 Instructor Medical-Surgical Nursing Undergraduate Program School of Nursing The University of Michigan Ann Arbor, Michigan Summer, 1987 Staff Nurse Outpatient Clinics Internal Medicine The University of Michigan Ann Arbor, Michigan 1985-1987 Teaching Assistant Medical-Surgical Nursing Undergraduate Program School of Nursing The University of Michigan Ann Arbor, Michigan 1982-1985 Staff Nurse Neuro I.C.U. University Hospital The University of Michigan Ann Arbor, Michigan

Gail Fromes -2- Curriculum Vitae 1981-1982 Staff Nurse Medical-Surgical I.C.U. Ingalls Memorial Hospital Harvey, Illinois 1977-1981 Staff Nurse Medical-Surgical General Care Units Ingalls Memorial Hospital Harvey, Illinois PROFESSIONAL AND ACADEMIC MEMBERSHIPS American Association of Neuroscience Nurses 1996-Present Special Interest Group - Epilepsy American Association of Neuroscience Nurses 1996-Present Special Interest Group - Ambulatory Care American Epilepsy Society 1995-Present Epilepsy Foundation of America 1995-Present American Association of Neuroscience Nurses 1992-Present Michigan Nurses Association 1982-1985, 1990-Present Sigma Theta Tau 1985-Present American Association of University Professors 1987-1990 Graduate Student Teaching Assistant Association 1985-1987 PUBLICATIONS Articles Marzec, M., Edwards, J., Sagher, O., Fromes, G., and Malow, B.A. (2003). Effects of Vagus Nerve Stimulation on Sllep-related Breathing in Epilepsy Patients. Epilepsia, 44(7), 930-935. Malow, B.A., Edwards, J.C., Marzec, M., Sagher, O., Ross, D.R., and Fromes, G.A., (2001). Vagus Nerve Stimulation Reduces Daytime Sleepiness in Epilepsy Patients. Neurology, 57(9), 879-884. Kaur, A., Selwa, L., Fromes, G., and Ross, D.A. (2000). Persistent Headache After Supratentorial Craniotomy. Neurosurgery, 47(3), 633-636. Malow, B.A., Edwards, J.E., Marzec, M., Sagher, O., and Fromes, G.A., (2000). Effects of Vagus Nerve Stimulation on Respirations During Sleep: A Pilot Study. Neurology, 55(10), 1450-1454. Schuh, L.A., Henry, T.R., Fromes, G., Blaivas, M., Ross, D.A., and Drury, I., (1998). Influence of head trauma on outcome following anterior temporal lobectomy. Archives of Neurology, 55(10), 1325-1328.

Gail Fromes -3- Curriculum Vitae Malow, B.A., Fromes, G.A., and Selwa, L.M. (1997). Sleep attacks mimicking epileptic seizures and pseudoseizures. Journal of Epilepsy, 10(5), 232-235. Malow, B.A., Fromes, G.A., and Aldrich, M.S. (1997). Usefulness of polysomnography in epilepsy patients. Neurology, 48(5), 1389-1393. Rivet, S., and Fromes, G. (1991). Nursing care of the patient undergoing long-term monitoring. Horizons, 5(3), 18-19. Fromes, G. (1986). Effect of nursing interventions on intracranial pressure. Nursing Research Review, 2(4), 2. Abstracts Edwards, Jonathan C., Fromes, Gail A., and Sagher, Oren, (2002). Vagus Nerve Stimulation for Refractory Seizures in Developmentally Delayed Adults. Epilepsia, 43(Supplement 7), 339. Marzec, M., Edwards, J.C., Sagher, O., Fromes, G., Malow, B.A., (2001). Effects of Vagus Nerve Stimulation on Sleep-Related Breathing. Sleep, 24(Supplement ), A6. Malow, B.A., Edwards, J.C., Marzec, M., Sagher, O., Fromes, G., Weatherwax, K.J., (2001). Effects Of Vagus Nerve Stimulation on the Apnea-Hypopnea Index in Patients With Epilepsy. Neurology, 56(Supplement 3), A9. Edwards, J.C., Fromes, G.A., Holland, K.D., Sagher, O., Garton, H.J.L., and Ross, D.A., (2000). Vagus Nerve Stimulation in a Clinical Setting. Epilepsia, 41(Supplement 6), 107. Fromes, G.A., Edwards, J.C., Holland, K.D., Sagher, O., Garton, H.J.L., and Ross, D.A., (2000). Clinical Utility of On-Demand Magnet Use with Vagus Nerve Stimulation. Epilepsia, 41(Supplement 6), 117. Malow, B.A., Edwards, J.C., Marzec, M., Sagher, O., and Fromes, G.A., (2000). Effects of Vagus Nerve Stimulation on Respiration During Sleep. Epilepsia, 41(Supplement 6), 223. Malow, B.A., Edwards, J.C., Marzec, J.L., Ross, D., and Fromes, G., (2000). Effects of Vagus Nerve Stimulation on Sleep-Onset REM Periods and Daytime Alertness in Epilepsy Patients. Sleep, 23(2), A118. Malow, B.A., Edwards, J.C., Marzec, J.L., Ross, D., and Fromes, G., (2000). Effects of Vagus nerve Stimulation on Multiple Sleep Latency Tests in Epilepsy Patients. Neurology, 54(3), A27. Passaro, E.A., Ross, D.A., Nasreddine, W., Beydoun, A., Drury, I., Selwa, L., Blaivas, M., Malow, B., and Fromes, G. (1998). Similar Good Outcome With Lesionectomy or Lesionectomy Plus Hippocampectomy in Patients With Medically Refractory Epilepsy With Temporal Lobe Lesions. Epilepsia, 39(Supplement 6), 83. Selwa, L.M., Greenfield, L.J., Fromes, G., Drury, I., Henry, T.R., Passaro, E., and Ross, D.A. (1998). Distinguishing Features of Patients with Refractory Partial Epilepsy Not Offered Resection After Intracranial Monitoring. Epilepsia, 39(Supplement 6), 83. Ross, D.A., Fromes, G., Schuh, L.A., Henry, T.R., and Drury, I. (1995). Multiple Risk Factors and Outcome Following Epilepsy Surgery. Epilepsia, 36(Supplement 4), 73.

Gail Fromes -4- Curriculum Vitae Schuh, L.A., Fromes, G., Ross, D.A., Henry, T.R., and Drury, I. (1995). Risk Factors and Outcome Following Anterior Temporal Lobectomy. Epilepsia, 36(Supplement 4), 74. Pillai,A.P., Ross, D.A., Fromes, G.A., and Henry, T.R. (1993). Generalized Convulsions in Patients Whose Complex Partial Seizures Cease After Temporal Lobectomy. Epilepsia 34(Supplement 6), 46. Letter Fromes, G. (1990). Needle sticks. Today's Professional Nurse, 1(2), 22. PAPERS, WORKSHOPS, OR POSTERS PRESENTED “Overview of Epilepsy” presented for the Ann Arbor Epilepsy Support Group, University of Michigan Hospital, Ann Arbor, Michigan, April 2005 “Safety and Tolerability of VNS” presented for Registered Nurses and Physician Assistants, VNS Symposium, Las Vegas, Nevada, July 2004 “Psycho-Social Aspects of Epilepsy” presented for the Clinical Neurophysiology Lab Technical Staff, University of Michigan Hospital, Ann Arbor, Michigan, April 2004 “New Treatments for Epilepsy” presented for the Neurology Clinic Clerical Staff, University of Michigan Hospital, Ann Arbor, Michigan, November 2002 “Overview of Epilepsy” presented for the Ann Arbor Epilepsy Support Group, University of Michigan Hospital, Ann Arbor, Michigan, September 2002. “Medications for Epilepsy” presented for the Neuro Nursing Staff, University of Michigan Hospital, Ann Arbor, Michigan, April 2002. “Innovative Treatments in Neurological Disease: A Nursing Perespective on Vagus Nerve Stimulation”

presented for Nursing Grand Rounds, University of Michigan Hospital, Ann Arbor, Michigan, November 2001.

“Epilepsy Update” presented for the Ambulatory Care Nursing Staff, University of Michigan Hospital, Ann Arbor, Michigan, October 2001. “Epilepsy” presented for the Professional Support Staff Team of the Neurology Clinic, University of Michigan Hospital, Ann Arbor, Michigan, October 2001. “Overview of Epilepsy” presented for the Ann Arbor Epilepsy Support Group, University of Michigan Hospital, Ann Arbor, Michigan, September 2001. “Epilepsy Treatment Update” presented for the Ann Arbor Epilepsy Support Group, University of Michigan Hospital, Ann Arbor, Michigan, January 2001. “Educating the Epilepsy Patient” Telephone-Conference presented for Nurses, American Epilepsy Society, October 2000. “Epilepsy Nursing for The New Millennium: Vagus Nerve Stimulation” presented for the American Association of Neuroscience Nurses Meeting, New Orleans, Louisiana, March 2000.

Gail Fromes -5- Curriculum Vitae “ Vagus Nerve Stimulation” presented for Community Nurses, The Crowne Plaza Hotel, Ann Arbor, Michigan, February 2000. “Overview of Epilepsy” presented for the Ann Arbor Epilepsy Support Group, University of Michigan Hospital, Ann Arbor, Michigan, September 1999. “Vagus Nerve Stimulation” presentation with Dr. Jonathan Edwards for Patients and Family Members, University of Michigan Hospital, Ann Arbor, Michigan, June 1999. “Epilepsy” presented for the Professional Support Staff Team of the Neurology Clinic, University of Michigan Hospital, Ann Arbor, Michigan, May 1999. “Vagus Nerve Stimulation” presentation with Dr. Jonathan Edwards for the Operating Room Staff, University of Michigan Hospital, Ann Arbor, Michigan, February 1999. “Vagus Nerve Stimulation” presentation with Dr. Jonathan Edwards for the Clerical Staff of the Neurology Clinic, University of Michigan Hospital, Ann Arbor, Michigan, January 1999. Selwa, L.M., Greenfield, L.J., Fromes, G., Drury, I., Henry, T.R., Passaro, E., and Ross, D.A. “Distinguishing Features of Patients With Refreactory Partial Epilepsy Not Offered Resection After Intracranial Monitoring.” Poster presentation at the American Epilepsy Society Meeting, San Diego, California, December 1998. Passaro, E.A., Ross, D.A., Nasreddine, W., Beydoun, A., Drury, I., Selwa, L., Blaivas, M., Malow, B., ans Fromes, G. “Similar Good outcome With Lesionectomy or Lesionectomy Plus Hippocampectomy in Patients With Medically Refractory Epilepsy With Temporal Lobe Lesions.” Poster presentation at the American Epilepsy Society Meeting, San Diego, California, December 1998. “Vagus Nerve Stimulation” presentation with Dr. Jonathan Edwards for the Nursing Staff of the 4B Neuro Inpatient Unit, University of Michigan Hospital, Ann Arbor, Michigan, December 1998. Malow, B.A., Aldrich, M.S., Morton, K.J.,and Fromes, G.A.,"Polysomnography in Epilepsy Patients- Indications and Results." Poster presentation at the American Epilepsy Society Meeting, Baltimore, Maryland, December 1995. Ross,D.A., Fromes, G., Schuh, L.A., Henry, T.R., and Drury, I., "Multiple Risk Factors and Outcome Following Epilepsy Surgery." Poster presentation at the American Epilepsy Society Meeting, Baltimore, Maryland, December 1995. Schuh, L.A., Fromes, G., Ross, D.A., Henry, T.R., Drury, I., "Risk Factors and Outcome Following Anterior Temporal Lobectomy " Poster presentation at the American Epilepsy Society Meeting, Baltimore, Maryland, December 1995. "Role of the Clinical Nurse Specialist in the Epilepsy Surgery Program," presented as part of Grand Rounds, Department of Neurology, The University of Michigan, Ann Arbor, Michigan, October 1995. “Nursing Considerations for the Patient Undergoing Epilepsy Surgery," presented for the Twelfth

Annual Neuro Critical Care Conference, The Michigan League, The University of Michigan, Ann Arbor, Michigan, March 1994.

Gail Fromes -6- Curriculum Vitae Pillai, A.P., Ross, D.A., Fromes, G.A., and Henry, T.R., "Generalized Convulsion in Patients Whose Complex Partial Seizures Cease Following Anterior Temporal Lobectomy." Poster presentation at the American Epilepsy Society Meeting, Miami, Florida, December 1993. "Surgical Intervention for Epilepsy: The Spectrum of Care." Panel presentation for the Tenth Annual Neuro Critical Care Conference, The Michigan League, The University of Michigan, Ann Arbor, Michigan, March 1992. “The Patient Undergoing Depth Electrode Placement," presented for the Nursing Staff of the 4B Neuro Inpatient Unit, University of Michigan Hospital, Ann Arbor, Michigan, June 1991. “The Patient Undergoing Depth Electrode Placement," presented for the Nursing Staff of the Neuro Intensive Care Unit, University of Michigan Hospital, Ann Arbor, Michigan, June 1991. "Effects of Sex Difference and Hippocampal Lesions on Exploratory Behaviors and Wayfinding Performance in Rats in a Novel Environment," presented for the Graduate Student Nursing Research Symposium, University of Michigan, Ann Arbor, Michigan, April 1987. "Issues in Evaluation of Hospital Nursing Orientation Programs: A Review of the Literature," presented for the Nursing Education Committee, University of Michigan Hospital, Ann Arbor, Michigan, January 1987. "The Effect of a Single Visual Cue on Place Navigation in Rats with Bilateral Hippocampal Lesions." Poster presentation at the Graduate Student Nursing Research Symposium, The University of Michigan, Ann Arbor, Michigan, May 1985. "Patient Teaching in the I.C.U.," presented for the Summer Nursing Extern Program participants, University of Michigan Hospital, Ann Arbor, Michigan, June 1984. "Intracranial Hypertension: Mechanisms for Care," presented for the Advances in Critical Care Nursing Practice Symposium, Ann Arbor, Michigan, November 1983. Intracranial Hypertension: Mechanisms for Care," presented for the Advanced Critical Care Nursing Course, University of Michigan Hospital, Ann Arbor, Michigan, October 1983. COMMITTEES, PRECEPTORSHIPS, AND ADMINISTRATIVE POSITIONS Preceptor Nursing 506: Bio-Behavior II 2001 Clinical Practicum School of Nursing Graduate Program The University of Michigan Preceptor Nursing 506: Bio-Behavior II 1999 Clinical Practicum School of Nursing Graduate Program The University of Michigan

Gail Fromes -7- Curriculum Vitae Preceptor Nursing 262: Transition to 1998 The Graduate Nurse Role Clinical Practicum Nursing Department Washtenaw Community College School of Nursing Undergraduate Program The University of Michigan Preceptor Nursing 428: Client Care 1997 Management in Health Care Systems Clinical Practicum Preceptor Nursing 505: Bio-Behavior 1995-1996 Clinical Practicum School of Nursing Graduate Program The University of Michigan Member Advanced Nursing Practice 1995 Task Force Department of Nursing The University of Michigan Member Brief Visit Clinic Task Force 1992 Department of Neurology The University of Michigan Member Epilepsy Education Committee 1990-1994 Department of Neurology The University of Michigan Member Election Committee 1989 School of Nursing The University of Michigan Member Information Technology Task Force 1989 School of Nursing The University of Michigan Member Student Awards Committee 1987-1990 Medical- Surgical Nursing Program School of Nursing The University of Michigan Member Planning Committee 1986 Graduate Student Nursing Research Symposium School of Nursing The University of Michigan

Gail Fromes -8- Curriculum Vitae Member Planning Committee 1984 Advances in Neuro Critical Care Nursing Conference Neuro I.C.U. University Hospital The University of Michigan Charge Nurse Neuro I.C.U. 1982-1985 Preceptor University Hospital The University ofMichigan Preceptor Medical-Surgical I.C.U. 1982 Ingalls Memorial Hospital 5/05

Clinical utility of on-demand magnet use with vagus nerve stimulation Gail A. Fromes, Jonathan C. Edwards, Katherine D. Holland, Oren Sagher, Hugh L. Garton, Donald A. Ross Rationale: Vagus nerve stimulation (VNS) is increasingly used as adjuvant therapy for medically refractory seizures. Intermittent stimulation helps prevent seizures in a substantial number of patients. For patients that continue to have seizures, placing a magnet over the stimulator at the onset of a seizure is often used to try to abort or shorten the seizure, although published data on the efficacy of magnet use is limited. We present data on clinical experience of magnet use with vagus nerve stimulation. Methods: 36 patients underwent implantation of a vagus nerve stimulator for medically intractable seizures at the University of Michigan and had seizures of sufficient duration to allow opportunity for magnet use. Their devices were activated 2 weeks after surgery, and stimulation parameters were gradually titrated up as tolerated. Magnet-induced stimulation was set 0.25 mA higher than the intermittent stimulation settings. Patients and their caregivers were encouraged to use a magnet at the onset of a seizure whenever possible. Strict semiological seizure calendars were kept, including clinical outcome with magnet use. Patients were excluded if adequate follow up was not yet available (10 patients), or if they had become free of seizures and auras after implantation (2 patients). Results: The 24 patients included in this study ranged in age from 9-57 years. 10 patients (42%) were female. 18 patients (75%) had focal epilepsy, 2 patients (8%) had primary generalized epilepsy, and 4 patients (17%) had symptomatic generalized epilepsy. 5 patients had undergone prior focal resection and 1 patient had undergone corpus callosotomy. The average number of antiepileptic medicines that had been tried was 8. At latest follow-up, 9 patients (38%) experienced abrupt cessation of at least 50% of their seizures when they used a magnet. 9 patients (38%) experienced shorter seizures, 5 patients (21%) experienced decreased seizure intensity and 4 patients (17%) reported reduced postictal symptoms when the magnet was used. 1 patient (4%) reported no effect. Side effects occurring during stimulation included coughing, tingling sensations, and voice changes. Conclusions: In this series, many patients were able to abruptly terminate their seizures with magnet use. A majority was also able to shorten their seizures, decrease the intensity of their seizures or reduce their postictal period with magnet use. While VNS is increasingly employed as a means to prevent seizures, the utility of on-demand magnet use may be under-appreciated. An increased sense of control and empowerment may contribute to improved quality of life for patients with medically refractory seizures.

EDUCATING THE EPILEPSY PATIENT Gail Fromes, MS, RN, CNRN It is important for people with chronic illness and their family members to have a thorough

understanding of the condition affecting the patient and treatment. Education is required so those

patients can make informed decisions about healthcare and how to live optimally with the

condition over the lifespan. Epilepsy patients have an enormous need for education in a variety

of areas. Education can be a challenge as these patients often are affected with 2 problems that

compromise their ability to learn. The first is memory impairment and the other is intellectual

impairment. Memory impairments can occur, related to the seizure focus or possibly due to

medication effects. In temporal lobe epilepsy, for example, the seizure focus may be directly in

the area thought to be responsible for memory function. Due to cellular changes, such as mesial

temporal sclerosis, the normal function of the cells (memory) becomes impaired. Medication also

plays a role in impairment of memory possibly due to sedative effects, which make patients less

able to attend to material being presented. Neuropsychological testing often reveals significant

memory impairments in the epilepsy patient and IQ scores can often tend to be in the 70-80

range. If one considers that college students can typically have IQ’s above 100, the need for

simple explanations becomes evident in the epilepsy patient. Each patient is an individual, and

that has to be kept in mind, but in looking at patient populations with partial epilepsy as a whole,

trends toward impaired memory and intellectual function are evident.

While each section presented tonight could comprise a 20 minute discussion in itself, I

will try to briefly share what has worked for me in ten years of providing nursing care to epilepsy

patients. More specifics can be addressed in the question and answer session.

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Individualize Education

What does the patient/ family member WANT to know?” What does the patient/ family

member NEED to know? Try to balance these issues. There is information that we must supply

as nurses, but pay attention to the questions that the patient and family members are asking for

special areas of focus. Remember that if the patient has a seizure right before or immediately

after information is given, the patient will probably retain little, if any, of it, and the information

will have to be repeated. In the inpatient setting, patients can be taught when they come in for

long–term monitoring, if they are in a seizure free interval or the outpatient setting can also be

used. It can be done over the phone, but face-to-face contact is often optimal with the

opportunity to write things down and provide written information at the same time.

Epilepsy

Patients need a simple explanation of what epilepsy is. I usually describe how nerve cells

transmit a chemical between them for normal movement and activity etc. In a seizure, this

chemical discharges on it’s own and overexcites or there is not enough chemical to stop this

abnormal transmission. A seizure takes place when this chemical transmission suddenly takes

place in the brain and causes abnormal movement, sensation and/ or loss of awareness. Epilepsy

is the syndrome of repeated seizures. Millions of people will have a single seizure in their lives

due to fever, electrolyte imbalance, etc. and this is NOT epilepsy. For many, the cause of their

seizures is not identified. Sometimes, there is a known cause – tumor, infection, head injury etc.

These conditions may result in cellular damage, leading to seizures.

Diagnostic Evaluations

Epilepsy patients often undergo extensive diagnostic evaluations. These tests carry many

complicated names and often are confusing to the patient. There are several types of scans (MRI,

PET. SPECT) and all should be simply explained to patients. They will need to know what the

experience will be for them and what information is hoped to be gained by this scan, in relation to

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their treatment. Epilepsy surgery patients will often undergo the most diagnostic evaluations of

the epilepsy population. EEG’s are quite important and it is possible to break down the results

into the simple fact that the EEG was diagnostic of a certain type of epilepsy, or primarily

nondiagnostic. If the latter, reassurance can be given that other types of EEG’s might be used if

needed, such as inpatient CCTV- EEG recording of seizures. Not all patients with epilepsy will

have abnormal findings on outpatient EEG’s.

Medications

Medications require explanation of expected therapeutic effects, dosing, and side effects.

There may be special instructions pertinent to the individual medication. A simple explanation of

how these drugs work (to quiet down the extra activity of the cells) is usually all that is needed.

Actually for many drugs “ the exact mechanism is unknown” and if patients are told this, they

may become alarmed. Reassure them this is the case for many drugs, including aspirin. All

drugs went through investigational testing before being released and the FDA oversees the

process. Very specific information must be given about some drugs. For example, in the case of

some long-acting drugs, patients must be aware that they may see the outer caplet in their stool

and that this is to be expected; the outer coating may not be crushed or destroyed, etc. Rash may

occur with any drug and it is vital that patients notify providers immediately if this occurs. Some

drugs carry a higher risk of Stevens-Johnson syndrome. Write down specific information like

this for the patient on a separate page with their dosing instructions. Alcohol and recreational

drugs should not be used. Compliance can be a major area of concern and education about why

consistent drug levels must be maintained can be of prime importance. Brochures and general

information about each drug are readily available from the drug companies, although some of the

information is too complex for the patients to understand and must be reviewed carefully with

them.

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Epilepsy Surgery

Epilepsy surgery patients need a great deal of information describing the purpose of their

diagnostic evaluations and the results. Caution should be used when setting expectations in

regard to how the evaluations are contributing to localization of a seizure focus and ultimate

surgery. For most centers, the ultimate decision for surgery will be made by a group of

professionals after review of all the data. Patients may need these recommendations repeated and

explained several times, as the localization process might be quite complex. All professionals

involved should be giving the patient the same information. Often, risks and specifics in regard

to the actual procedure are best left to the surgeon. If the patient voices concerns or questions

about what another professional has said, it is often desirable to have that professional talk to the

patient again or clarify what has been said with that provider before you speak to the patient.

Appropriate expectations must be set for outcomes and patients informed that medications would

have to be continued after the surgery, at least for awhile.

Vagus Nerve Stimulation

Vagus nerve stimulation is another treatment that is gaining popularity. Patients need

clear expectations that for most, it will only offer a reduction in the numbers of seizures.

Medications will have to be maintained, for most patients. An advantage to VNS is the

opportunity to try to abort seizures with the magnet and appropriate magnet application must be

explained to the patient and family member.

Ketogenic Diet

Ketogenic diet, used in children, will have to be understood by the parents and strictly

adhered to in order to be successful. Dieticians often work with these patients.

Safety

Safety is a major issue for persons having seizures. Standard activity limitations include:

no driving, operating mechanized equipment, or using sharp implements; no working at heights,

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with hot stoves, or near standing bodies of water; no swimming alone and take showers instead of

baths. Family members should be instructed in emergency care during a seizure and when to call

911 and seek medical attention.

Driving

The driving restrictions are often hardest for patients. Driving laws are regulated by each

State and the seizure-free interval required to drive varies from State to State. When patients

become angry about this issue, I tell them that each year, in our epilepsy clinic, we have patients

injure or kill themselves, or they have injured or killed others, because of having a seizure while

driving. I stress that this is difficult for us, as providers, to witness, and hopefully makes the

rationale behind this recommendation obvious. Also, it stresses that we understand the

difficulties and do not just blithely put out the restrictions. It presents the information in a more

humane way and often makes patients more receptive to education about this issue.

Pregnancy

Women of childbearing age with epilepsy require abundant education. They should be

taking folic acid supplements and the risks of pregnancy should be discussed. Female patients

should be told that, providers need to know if a pregnancy is planned so that optimal

anticonvulsant regimens can be prescribed for them, if refractory, and folic acid supplements

started before the woman becomes pregnant. Too often, women arrive in clinic 6-8 weeks

pregnant before the provider is informed. The most critical time is the first 11 weeks or so in

terms of anticonvulsant effects on the developing fetus. Ultrasounds and amniocentesis will help

to detect birth defects and reassure women as the pregnancy progresses. Statistics have shown

that with proper medical care, pregnant women with epilepsy have a 90% chance or higher of

having a normal, healthy baby. Women must also plan for care of the baby. If they are having

seizures with loss of awareness, assistance will be needed with childcare and how they personally

interact with the child. For example, carrying the baby is not optimal due to risk of sudden

6

seizure and dropping or injuring the child. Close follow-up with medication levels, and dose

adjustments are needed for the patient both during and after pregnancy. Vitamin K, to prevent

anticonvulsant clotting abnormalities, is often prescribed at the end of pregnancy and this will

have to be explained. Breast-feeding may or may not be permitted depending on the

anticonvulsant being used.

Teaching Tips

There are a few teaching tips I would suggest when working with epilepsy patients. The

first is to learn to become comfortable with telling patients how much is NOT known about

epilepsy. We don’t always know why epilepsy occurs, why some drugs work for some people

and others do not, why some people are refractory, why epilepsy surgery works for some and not

others, etc. It is helpful to point out that research is ongoing in these areas.

A second tip is to write everything down for patients or provide printed material. If there

are medication changes, list a few steps and then have the patient or family member call after

completion of these and then you give the next set of changes. Rarely, if ever, are plans for

several months’ worth of changes able to be followed, and often problems result, and the entire

schedule has to be revised. If the patient needs to bring records, films, etc., to the next clinic

visit, write this down. If the patient is to call you or someone else with an update, give specifics

on the time frame for the call and your number. It is helpful to provide the patient with a written

sheet of instructions and pertinent “bullets” of information discussed in clinic or inpatient unit.

Tell patients to put this sheet on their refrigerator where they will not lose it. Use simple

language and simple explanations. Keep a copy of any instructions that you write out. Then, if

patients lose them, you can easily copy and mail it to them. Or, if patients are having problems

with medication changes, you will be able to reference your copy during a phone call. You may

have some type of form available that has carbon in it and makes another copy as you write. This

can save time running to the copy machine. Also, medication instructions given over the phone

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are often best followed up with a letter with written instructions. Have the patient or family

member write down the instructions and repeat the medication changes back to you at the end of

the phone call.

Another tip is to teach the patients to log their seizures in a simple manner using a coding

system. For example, use “G” for grand mal and “S” for small seizure, etc. Work out the coding

specific to each patient and write down the coding system. Some patients and family members

may have their own coding systems already in place and go along with these if they are clear and

reasonable. Be sure you understand very specifically what type of seizure the letter or number

represents, if the family has their own system. A regular calendar can be used. It is very difficult

for you or the patient to assess the effectiveness of a treatment without the seizure calendar.

Patients may miss some seizures or forget to write them down, but a calendar at least gives you

and the patient a start. It’s very hard to interpret subjective comments from the patient such as “I

think I’m better”.

Epilepsy Foundation of America has a number of extremely helpful and educational

videos and brochures. Contact them at 1-800-EFA-1000 or www.epilepsyfoundation.org to receive

a catalog.

The last recommendation is to repeat, repeat, and repeat. This will become part of your

routine if you spend any length of time with these patients. Initially, I was surprised by their

memory problems and it took me awhile to get used to this. However, now I find myself

repeating things fairly easily. You might wish to check with the patient “ Do you remember what

we discussed the last time about your scan?” and then see what needs to be repeated. I also

explain why they have memory problems, as many are acutely aware of them. Some are

concerned that they have another disease process such as Alzheimer’s. For most patients, this

will not be the case, and it is reassuring for them to know that memory problems are related to

their epilepsy and the medications they are taking.

http://www.epilepsyfoundation.org/

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Educating the epilepsy patient, while very challenging, can be very rewarding, and

comprises an essential component of the nursing process with this patient population. I hope that

I have provided some assistance for you and your practice.

References

Engel, J., & Pedley, T. (Eds.). (1998). Epilepsy: A Comprehensive Textbook. Philadelphia: Lippincott-Raven.

Wyllie, E. (Ed.). (1997). The Treatment of Epilepsy: Principles and Practice. Baltimore: Williams & Wilkins.

Epilepsy Nursing for the New Millennium: Vagus Nerve Stimulation Gail Fromes, MS, RN, CNRN Content outline I. VNS Overview A. Description of system B. Theories of mechanism of action C. Investigational studies II Establishing a VNS program

A. Patient selection B. Professional staffing C. Insurance reimbursement

III Nursing care

A. Pre Implant 1. Assessment 2. Education

a. Realistic expectations b. Preparing for surgery

B. Post Implant 1. Assessment

2. Adjusting parameters 3. Education

a. Safety b. Magnet use

IV. Patient Experience

A. University of Michigan experience B. Examples of Efficacy 1. Complete seizure control

2. Improved seizure control 3. Change in seizure/ postictal interval

Epilepsy Nursing for the New Millennium: Vagus Nerve Stimulation

Gail Fromes, MS, RN, CNRN Content outline con’t IV. Outcome Measures A. Seizure control B. Seizure semiology

C. Postictal period D. Headache E. Memory F. Depression G. Quality of life

Epilepsy Nursing for the New Millennium: Vagus Nerve Stimulation Gail Fromes, MS, RN, CNRN Additional References: Asconape, J. et al. (1999). Bradycardia and asystole with the use of vagus nerve stimulation for the treatment of epilepsy: a rare complication of intraoperative device testing. Epilepsia, 40(10), 1452-1454. Henry, T. et al. (1998). Brain blood flow alterations induced by therapeutic vagus nerve

stimulation in partial epilepsy: I. Acute effects at high and low levels of stimulation. Epilepsia, 39(9), 983-990.

Labar, D. et al. (1998). Vagus nerve stimulation for symptomatic generalized epilepsy. Epilepsia, 39(2), 201-205. Labar, D. et al (1999). Safety and tolerability of early postoperative vagus nerve stimulator activation. Epilepsia, 40 Supp. 7, 216. Morris, G. et al. (1999). Long-term treatment with vagus nerve stimulation in patients with refractory epilepsy. Neurology, 53(7), 1731-1735 Labiner, D. et al. (1999). Shorter pulse width of VNS is as effective as standard stimulation. Epilepsia, 40 Supp. 7, 141. Uthman, B.M. et al. (1993). Treatment of epilepsy by stimulation of the vagus nerve. Neurology, 43, 1338-1345. Whitworth et al. (1999). Vagus nerve stimulation for intractable epilepsy: a series of 50 patients operated on at one center and with a comparison of two cycle types. Epilepsia, 40 Supp.7, 240.

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