The House That Jack Built:

How One Woman and Her Dog Support Interventional Radiology at Penn

BY SUSAN I. FINKELSTEIN

In 1978, amidst the turmoil of the Iranian Revolution, Mohammad and Mino Ebrahimi emigrated to the United States to build a better life for themselves and their two young daughters, Mina and Mariam. In the same year,"Connections," a documentary television series, aired its first episode. The show detailed how history is filled with seemingly unrelated events that are actually connected in the most surprising ways. Mina Ebrahimi's life lends itself to its own special set of "connections" occurrences that, link by link, have led her here to Penn Vet. The last link, specifically, came in the guise of a chocolate Labrador retriever named "Jack," but the process had been set in motion much earlier.

At the age of nine, newly settled with her parents in America, Mina was introduced to the food-service industry - eventually her life's work - at a small bakery the Ebrahimis bought in Seven Corners, Va. Her family's success soon allowed them to purchase the Daily Croissant, and later, in 1988, a restaurant in the Tysons Galleria mall called the St. Germain Cafe. Here Mina learned the art of multi-tasking: cooking, washing dishes, waiting tables and managing. In her process of becoming "Americanized," Mina made fast friends at the Galleria, connections that would later help her develop business contacts when the Ebrahimis expanded their café into a catering business. Her long-term relationships with organizations like the AIDS Foundation, the Ronald McDonald House, the Washington Redskins and the Easter Seals all had their roots here, where mall management turned to the Ebrahimis for catering conferences and local holiday events.

"Just getting the business off the ground and building a consistent clientele was hard," Mina admits. "But the catering business got so big because there is such a need for it in the whole Washington area. "Today, St. Germain Caterers, run solely by Mina, serves the entire region, with customers ranging from government officials to pharmaceutical companies. Equally far-reaching is Mina's generosity; she has supported charities as diverse as the American Red Cross, Fairfax Fire and Rescue and Women in Technology, to name a few.

Enter Jack

In fact, in 2003 this largesse prompted Mina to cheer up a despondent family friend, Sarah Miller, by presenting her with a small brown puppy she called "Jack." All was well until Jack became lethargic, refused to eat and was vomiting frequently. Soon blood appeared in his urine and he had severe diarrhea. Two veterinarians in the Virginia area each diagnosed a urinary tract infection and sent him home with antibiotics. Jack showed no improvement. Mina paid the rising medical bills, and Sarah suggested they become co-owners of Jack.

Finally, a third veterinarian, suspecting the puppy's condition was more serious, ran blood work. Enzyme levels indicated that Jack had a liver shunt, a congenital problem in which the liver is deprived of a blood supply and cannot develop properly. Many puppies can live with the small functioning portion of the liver for a short period but usually die if the situation remains uncorrected. The doctor recommended a procedure to surgically close the shunt, and Mina readily agreed.

Then, at 10:00 on the night before the surgery, Jack's veterinarian called with some last-minute guidance. "He asked me if I was willing to travel to Philadelphia," Mina remembers, "where there was a surgeon who was doing a new procedure. Of course, I was willing!" In two weeks' time, Jack and Mina had an operation scheduled at the Ryan Veterinary Hospital with Dr. Chick Weisse,V'98, assistant professor of soft tissue surgery.

It takes a team. . .

Rather than traditional veterinary surgical procedures that require large incisions and can be risky, Dr.Weisse and the surgery team used a minimally invasive interventional radiology technique that, until recently, had only been performed on people. Metal coils were inserted into the shunt to promote coagulation, eventually closing off the unusually large hole in Jack's liver. The operation was a success, but about a month later, when the dog was being weaned off his medications and his low-protein diet, things took a turn for the worse. He again became lethargic and depressed, was pale, and had a belly full of fluid. Once again, Mina brought Jack to several local veterinarians and a veterinary referral hospital; at each place, doctors recommended putting the young dog to sleep because of limited treatment options. Never giving up hope, Mina decided to come back to Penn.

Dr. Allyson Berent, Waltham Lecturer in Minimally Invasive Diagnostics and Therapeutics and lecturer in small animal internal medicine, remembers her first encounter with the pair. "They came in through the Emergency Service and Jack was transferred to Internal Medicine the next morning. I took his case, and it just turned out that he had a bad gastric ulcer. Because of the ulcer, he was losing lots of blood and protein. We gave him about 12 plasma transfusions and five or six blood transfusions. We treated him medically with different antacids and gastrointestinal protectants, time and support. It took a lot of time and persistence. We needed to give the ulcer time to heal. We also put him back on the shunt medications."

A recurrence of the ulcer in 2004 met with the same bleak, previous prognoses: three emergency veterinary clinics in Virginia determined Jack would not live very long and should be euthanized. It was the Friday before Memorial Day, and most people were beginning their long holiday weekend. Frantic and in tears, Mina telephoned Dr. Berent and caught her on her way to a family event in New York.

"Mina's local vet said the dog had a perforated intestine and was septic, so would have to be put to sleep," recalls Dr. Berent. "I said, 'Mina, don't put him to sleep. Bring him here and let's be sure of what is going on.' So Mina got here late Friday night."

Per Dr. Berent's instructions, Jack was kept alive via fluids and more blood and plasma until Monday, when she returned. Even the Ryan staff members, however, were unsure if he would make it. First thing Monday morning, Dr. Berent examined Jack and decided to continue with steady medical treatment, as each day he was improving slowly. He went home nearly one week later. Over the following year, as Jack was slowly weaned from the medication, his protein levels came up and eventually all his liver functional testing was normal.

Mina is still emotional when she remembers Dr. Berent's painstaking care. "I was very thankful.You could really feel Allyson's caring. She was so supportive and encouraging, saying,'Don't worry. Hang in there. Give him time and we'll see. He's going to be okay.' Some nights she even stayed at the hospital with Jack." And because of the experience they shared, Mina and Allyson have since become close friends.

"He was a little runt, and now he's 92 pounds," Dr. Berent laughs. "Usually dogs with shunts never grow to full size, and he just grew and grew and did great. He's totally off his meds now and is completely fine." Because she is so grateful to staff at the Ryan Veterinary Hospital for saving Jack's life when so many others had written him off, Mina will contribute a portion of St. Germain Caterers' profits to the Hospital. Through this ongoing gift, Mina is excited to be able to fund the Jack Miller-Ebrahimi Program for Interventional Endoscopic and Radiologic Diagnostics and Therapeutics here. Truly, the connections that have brought Mina to the Hospital will benefit animals for years to come.


The ABCs of IR at Penn Vet

Many of Penn's veterinary specialists are pushing forward new disciplines. This is certainly true of the Minimally Invasive Interventional Radiology and Interventional Endoscopy Service at the Matthew J. Ryan Veterinary Hospital. This program is the first of its kind to be established at any veterinary teaching hospital in the country. Drs. Chick Weisse,V'98, assistant professor of soft tissue surgery, and Allyson Berent, Waltham Lecturer in Minimally Invasive Diagnostics and Therapeutics and lecturer in small animal internal medicine, are performing minimally invasive and surgical techniques for such ailments as tumors, liver shunts, urinary stones, bile-duct obstructions, tracheal collapse and life-threatening nose bleeds. Their specialty is referred to as interventional radiology.

An established tool in human medicine, interventional radiology has tremendous potential for the treatment of serious maladies in pets. Interventional radiology involves the use of contemporary imaging methods to deliver therapeutic materials to different systems. The veterinary community is acquiring and refining similar procedures as human medicine to provide nonsurgical alternatives with decreased morbidity/mortality rates, minimal anesthesia time, shorter hospital stays and lower costs.

Interventional radiology utilizes fluoroscopy to visualize the placement of catheters, stents, balloons and coils into blood vessels, the urinary system, the respiratory system and other tubular structures. Interventional endoscopy uses an instrument called the endoscope under fluoroscopic guidance for diagnostic and therapeutic endeavors like clearing malignant obstructions in the urethra, ureter, bladder, common bile duct or intestines/colon; opening strictures in the urinary system, nasal passages, trachea or intestine; relieving bile-duct obstructions secondary to obstructive pancreatitis, choleliths, infection or tumors; and pulverizing stones in the urinary or biliary system, a process known as lithotripsy. These procedures are still largely experimental in animals and being studied at Penn for many different applications in our companion animal patients.

For more information about Interventional Radiology please see the Web site at www.vet.upenn.edu/ departments/csp/crossdiscipline/ir/