Changing Course, Finding a Home

From his position as a transfusion medicine physician, Jay Raval, MD, collaborates with providers from across UNC Medical Center to coordinate the best treatments for patients, while also giving him the chance to study ways to improve that care. His efforts have earned him this year’s Woods Junior Faculty Award.

Changing Course, Finding a Home click to enlarge Jay Raval, MD (Photo by Lane Deacon / UNC Health Care)

As an undergraduate at UNC, Jay Raval, MD, knew he was interested in becoming a doctor. He just didn’t have a clear answer for why. As a star student, he could have coasted into medical school, but he needed to experience medicine outside of the classroom first – something to help him explain the path he found himself on.

During his junior year at UNC, Raval worked as an EMT in the evenings and on the weekends. And in between classes, he was the assistant to the school nurse at a Chapel Hill elementary school.

“Being an EMT and working with a school nurse are probably on the opposite ends of the intensity spectrum,” Raval said. “But both experiences taught me different things about medicine, how to think quickly in stressful situations, and how to build bonds with patients.”

When Raval did complete medical school, also at UNC, he envisioned himself going into surgery. But during his residency at the University of Pittsburgh, he saw his plans shift to his current field of transfusion medicine.

“It was pretty daunting to make that transition, but I found something I really loved in pathology and transfusion medicine,” Raval said.

Now, Raval, assistant professor in the department of pathology and laboratory medicine, and medical director for therapeutic apheresis, has earned the Woods Award, an annual award that honors clinical excellence at UNC.

For our latest Five Questions feature we talked to Raval about his clinical responsibilities, his ongoing research, and what he calls a “spa treatment for your red blood cells.”

While you were still an undergraduate, you worked as both an EMT and a school nurse assistant. How did you come to those roles and what did you learn from them?

I realized that if I wanted to be more confident about my choice to pursue medicine, then I needed to get some hands-on experience. Through the grape vine, I heard about a course offered at Durham Technical Community College that would get you credentialed as an EMT-Basic and didn’t require a lot of prerequisites. So basically, I signed up, paid my tuition, went through the class, and got my certification.

I had a lot of fun during my time as an EMT. It was stressful and exciting, and also helped confirm that I might have the skills necessary to become a doctor. That really boosted my confidence that this was the right direction for my life.

At the same time, I worked as an assistant to the school nurse at a local elementary school here in Chapel Hill. Through that experience, I learned the basics of taking vital signs, bandaging injuries, treating wounds, and other things that are really just the introduction to patient care. What I loved most was talking to the kids. Some were scared and you’d have to be reassuring and calm them down. Others would just come by the office a lot for little things and you’d get to really know them.

Your path to pathology was winding. How did you end up in this specialty?

All through medical school, I thought I’d go into general surgery. I matched into general surgery at the University of Pittsburgh and began my internship. I really enjoyed the operating room and made some close friends and worked with great colleagues that I’m still in touch with today. But I realized that I wanted a little more opportunity to pursue research interests.

When I was in medical school, transfusion medicine and apheresis were not really emphasized outside of a few lectures and some small group work. But my wife – whom I met and married in medical school – was a pathology resident in Pittsburgh, and I could see what she was doing and I became increasingly interested in the field. I found a home in transfusion medicine, which is an amazing blend of patient care and laboratory medicine. So, at that point, I focused specifically on that, completed my residency training, and did a transfusion medicine fellowship. My wife [Marian Rollins-Raval, MD, MPH, Medical Director, Special Coagulation Laboratory at UNC Hospitals] and I had the opportunity to come back home to UNC in 2012, which we were thrilled about.  It’s been awesome to come back to such a wonderful department.

You’ve had a lot of success in the clinical research arena, including a Clinical and Translational Science Award [CTSA]. What guides your research efforts?

In medical school, I realized that the answers we were being taught were moving targets that changed often. And what guides that change is research. I will freely admit that I’m not a rigorously trained scientist; I don’t have a funded lab or a PhD. There are plenty of clinician-scientists who can perform clinical care and then research other basic science concepts that may be very distant from their clinical work. But my brain just can’t bridge that gap. I’ve always known I wanted to do research that was highly translational and have acquired the skills in the lab necessary to do that.

I’m taking information from my patients and working to answer very specific clinical questions. My goals are immediate and focused on improving outcomes for patients.  Thankfully, I work in a great area and am constantly encouraged and supported to pursue these translational investigations by my department chair Dr. Charles Jennette, laboratory medicine director Dr. Herb Whinna, and Transfusion Medicine Services director Dr. Yara Park.

The CTSA Award came out of work we are doing with our sickle cell patients. The project is a partnership with folks at Duke and it’s been really wonderful to see what started as a theoretical idea transform into such an interesting project with the possibility to really impact the care of these patients.

It’s focused on an FDA-approved process for “rejuvenating” blood stored in blood banks before transfusion. We will be testing the impact this process can make for patients with sickle cell disease who require regular transfusions.

Right now, the FDA allows for banked blood to be stored for up to 42 days. At UNC, most of our units are issued right in the middle of that time frame – 20 or 21 days – but we do have units that go all the way to 42 days that are transfused with no adverse effects. But, there’s a process called blood rejuvenation – some people call it a ‘spa treatment for blood cells’ – that gives the red cells the phenotype of a younger cell. Your average patient doesn’t need rejuvenated red cells, and since the rejuvenation process is laborious and expensive, it’s really only useful in select situations. However, for certain populations requiring regular transfusions – like patients with sickle cell disease – the blood rejuvenation process can potentially benefit them in a number of ways including red cells circulating longer in vivo, which would mean they might need fewer apheresis procedures, fewer transfusions, and fewer trips to the hospital. We have patients now who come in once a month for apheresis exchange transfusions and if we could spare these folks one or two visits a year, then that can make a big difference.

You also serve as medical director for therapeutic apheresis at UNC. Can you describe that practice and which patients benefit?

I sometimes refer to therapeutic apheresis as “smart bloodletting.” Basically, what we’re doing is taking out the patient’s blood and running it through an instrument that removes the fraction which contains the “bad things” that mediate a particular pathologic process that we don’t want and then returns the remaining blood back into the patient.

To the naked eye, the blood that you bleed is uniformly red, but it’s not a simple fluid like water. It’s heterogeneous. And the densest component in blood is the red cells.

So, for example, when we perform therapeutic apheresis on a patient with sickle cell disease, we can remove their sickle red cells effectively and replace them with non-sickle red cells from the blood bank.

Another patient group we help treat has a rare autoimmune disease called thrombotic thrombocytopenic purpura (TTP), which is a blood disorder that results in small platelet clots throughout the body. I describe it this way: the small but numerous platelet clots turn the normally smooth vessels into a terrain much like a rocky cave, and when blood tries to flow through these altered vessels, the red blood cells get torn up by the rough vascular terrain. This results in decreased blood flow and oxygen delivery to vital organs all over the body, such as the heart and brain.

TTP can go very bad very fast. When left untreated, the mortality rate is more than 90 percent. The first-line treatment for this condition is emergent therapeutic plasma exchange, which we offer here at UNC. We are constantly telling providers throughout the state: if you have someone with TTP, you need to get them to UNC as quickly as possible.

Considering these potential complications of TTP that can injure organs like the heart and brain, how do you collaborate with providers across other specialties to ensure the best care for these patients?

I am actually planning a project focused around TTP. UNC is a hotspot for TTP referrals and these patients are most often admitted to the ICU, so we rely on the expertise of providers there to care for these critically-ill patients. I actively engage and seek input from whatever specialists are involved in the care of our patients. These TTP patients have complications that require care from a hematologist, but we also work really closely with critical care, cardiology, nephrology, neurology, and others. The days of a provider siloing themselves off are over, and at a place like UNC where there are so many experts in the different specialties, one would be foolish to do that and our patients would not get the highest quality care.  

For this project, we’re looking into ways to measure metabolites in TTP patients that will hopefully eventually lead to the discovery of novel biomarkers for TTP; I’m collaborating closely with colleagues in several areas here at UNC to make this endeavor a success.

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