It was 1988, late on a Friday night, when the boy arrived in the Intensive Care Unit (ICU).
He was 16 years old, admitted after a terrible accident. Acute kidney injury caused his kidneys to stop removing waste products from his blood, and as the levels of waste in his blood rose to toxic levels – a condition called uraemia - his other organs began to fail too.
Young kidney specialist, Rinaldo Bellomo, was his doctor that night. Already a passionate medical researcher, he was studying the effects of a treatment called continuous veno-venous haemodiafiltration (CVVHDF).
Sure that dialysis would be unsafe for this young man and with plans to be away for the weekend, Rinaldo left a plan to stabilise the boy overnight, and begin CVVHDF in the morning.
“When I returned on Monday, I went straight to the ICU, bed 1, to see how this young patient had hopefully improved over the weekend,” Bellomo wrote about the event later.
The boy wasn’t there. He had died.
“The specialist on duty for the weekend had decided to countermand the plan. He prescribed dialysis. Within 20 min of the start of dialysis, the boy’s pupils became fixed and dilated and he died,” Bellomo wrote.
“I can still remember the emotions: a mixture of anger, frustration, indignation and sadness. I felt this boy had been killed by the reckless use of dialysis.”
Ever since, he says, “I have spent … years in the relentless pursuit of all the evidence that I could obtain to show clinicians what I felt I could see and what I felt so often they could not…”
Fast forward to November, 2016. Recent retiree Anthony is an enthusiastic cyclist – he has even ridden Canada coast to coast, and run in marathons. Tonight, however, he is struck by chest pain so intense he can’t sit still.
“My heart stopped beating – a cardiac arrest I suppose you’d call it,” Anthony says.
“My wife did CPR for eight minutes, before the fire brigade and then ambulance arrived and did it for another 35,” says Anthony.
He was rushed to Austin Health’s intensive care unit. Anthony has no recollection of his days there, nor the magic that unfolded.
Knowing that Anthony was coming, a flock of doctors and nurses were ready, waiting for him. Within seconds, they had assessed that he would be appropriate for a new research trial being run by the ICU’s research manager Dr Glenn Eastwood, under the guidance of Professor Rinaldo Bellomo.
A nurse opened the front envelope in a holder on the wall in the research corridor that says ‘CCC Cardiac Arrest trial’. The piece of paper that it contained assigned Anthony to the control group – to receive the standard care for a cardiac arrest, including receiving the standard concentration of carbon dioxide.
It’s like a lucky dip. But in this case, the prize is the potential that increased blood flow to the brain from receiving a higher dose of CO2 could result in the reduced release of toxic chemicals, reduced likelihood of seizures and ultimately, reduced chance of brain damage.
But Professor Bellomo emphasises that the real game of chance is the practice of medicine without pursuing evidence by conducting large randomised controlled trials. He’s adamant, too, that he doesn’t know whether being in the experimental or control group is better. “If we knew which treatment were better, that’s what we’d be doing!,” he says.
The trial has just received a major grant from the NHMRC (the National Health and Medical Research Council) – “to do the biggest cardiac arrest management trial in the history of humankind”, Rinaldo says. It is one of 19 named research trials and a number of smaller studies underway in the Austin Health ICU at the moment. Some 15 to 20 percent of patients are enrolled in a research trial on their way through.
After being in hospital for five weeks, Anthony is now home. Despite some early concerns, he has no brain damage. He has a freshly implanted defibrillator under his skin ready to give him an electric shock should his heart stop again, and still carries burn marks from the defibrillator that was used to restart his heart. “But I don’t mind! What I had is called a coronary arterial spasm, and has a 90 per cent mortality rate. I was clinically dead for probably 40 minutes and I’m doing very well. It’s a miracle,” he says.
For the third year in a row in 2016, Prof Bellomo was named one of the Thomson Reuters Highly Cited Researchers. The award places him in the top one per cent of researchers in the world in terms of influence and impact – those whose work has supported, inspired or challenged other scientists the most, and therefore been cited in research papers more than any others.
On the medical expert ranking website, expertscape, he ranked first in the world for expertise on acute kidney injury, and third for both critical care and intensive care.
When I go to visit, Bellomo is in his office in the Austin Health ICU, debating earnestly with colleagues about how to convince clinicians to drop the level of oxygen given to critically ill and anaesthetised patients, a reversal of 30 years of tradition.
“The biggest challenge of research is getting people to free their minds. People traditionally keep oxygen levels really high because they’re scared to do otherwise, but there’s evidence to suggest that it’s better for the brain – and probably the lungs – to bring the level down to about 90 to 92 per cent. That’s about the level you’d get at the top of Mt Hotham,” he says.
“People forget that a lot of the things we do now are not evidence-based. What we want is to be practicing randomised medicine, not random medicine,” Professor Bellomo says. It’s one of his signature sayings.
Bellomo – or Rinaldo, as he insists being called – wakes each day with a compulsion to do research that might be compared to the drive that sees musicians and artists wake with ideas that must be taken immediately to their instrument or canvas. In his final year of medicine, he would meet his nephrology professor at 3am to assist with medical experiments on rabbits.
As he gesticulates, photocopied journal articles flutter against the wall behind him. Four of his most influential New England Journal of Medicine (NEJM) articles take pride of place in the centre – and every spare bit of desk is covered in neatly overlapping clusters of papers, with research trial or journal names written neatly in permanent marker across the top.
Rinaldo has produced more than 1000 papers, 150 book chapters and edited 12 books on intensive care medicine: numbers that really represent thousands of lives saved, and even more greatly improved. Typically, it’s those articles in the NEJM – in which Rinaldo has been published 10 times – that go on to be the most influential.
Take his work on Medical Emergency Teams (METs), first introduced as a pilot project at Austin Health over 15 years ago. His most cited research on the outcomes, from the NEJM in 2011, has been cited hundreds of times and resulted in the introduction of METs as standard in both Australian hospitals, and worldwide.
“Research offers the chance to be a part of the attempt to improve care for every patient in the hospital,” he says.
“The changes in practice as a result of these trials have world-wide repercussions. I think it’s fair to say that we’ve saved people from thousands of cardiac arrests and saved lives worldwide,” he says.
Similarly, when Rinaldo and his team published research findings in the NEJM that showed that keeping ICU patients’ blood sugar levels low actually increases their chance of dying – despite being recommended at the time by a number of professional bodies - he says “we think we saved thousands of lives because of that.”
And – of course - it was a study on continuous renal replacement therapy that has been one of Rinaldo’s most influential: “Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients”, published in the NEJM in October 2009. Because of that work, Rinaldo says, “the use of continuous renal replacement therapy (CRRT) has grown from a few centres to the whole of Australia and then to many other countries to finally being the dominant form of acute renal replacement therapy in the world.”
“He wakes every morning and thinks: ‘what will I learn, discover and contribute today?’ It matters a lot to him that the work is fun; to seek excellence and enjoy doing it.”
Rinaldo is Austin Health’s director of ICU Research. The small research corridor houses Rinaldo’s office and that of three research nurses: the empire he has built since establishing the Research office in 1994. At any one time, there are generally a number of Research Fellows too, who have travelled to Australia from all over the world to work with Rinaldo. They frequently pay their own way, purely for the experience of working with him.
One of the research nurses’ roles is to go around the ICU each morning to assess which patients might be appropriate for each of the different trials. But these days research nurse Helen Young says: “The staff have usually already highlighted the patients they think might be appropriate before I even get there.”
Dr. Warrillow says that “Austin Health’s ICU has a higher number of patients participating in clinical research than anywhere else in Australasia, and possibly the world. Relatives are really stressed at the point when their loved one arrives here, but because of the way Rinaldo has normalised research, we find that everyone – nurses, registrars, or the allied health team – are very comfortable having a conversation with families about research, and usually, relatives say ‘sure’. And if they say no, they know what they’re saying no to.”
The research culture Rinaldo has built in the ICU has had an impact on every aspect of the department – and most significantly, on the care patients receive. “He’s normalised research as a standard part of clinical care, so that everyone is thinking: what opportunities are there for this patient to participate in clinical research?,” says Dr. Warrillow.
“What we see – and there’s evidence to support this – is that patients who participate in clinical trials actually do better. When you have an array of people focussing on one person’s clinical outcome and paying an excruciating amount of attention on improvements or deterioration, clinical care and research interact very favourably. It can’t help but impact on clinical outcomes for the better,” says Dr. Warrillow.
While there are few that compare to Austin Health’s ICU, Rinaldo says that intensive care units in Australia and New Zealand are “the envy of the world”, thanks partly to the work of the research and data-sharing Clinical Trials Group, an organisation in which Rinaldo plays a significant role. While it’s impossible to quantify the impact of one individual, Rinaldo is undoubtedly a key influence. “Australia and New Zealand have the best ICU outcomes in the world. We can’t prove it’s the research culture, but the two seem to go hand-in-hand.”
“But an association is not causation,” he warns.
As Rinaldo does his round of the ICU, he checks on the care of each patient – in one bed, a new mum separated from her newborn baby because she has pneumonia; in the next, a man who has been there for 60 days, and whose chest has just collapsed. As he does, he gently teases the staff, pushing them to question if they are delivering care that is truly based on the latest evidence. Somehow, it seems like he has read every research paper ever published. “Haven’t you read the latest paper on that yet?” he enquires of one surgeon. “It was in the New England last week!”
“Rinaldo gains great pleasure and internal reward from conducting and reading research. His idea of down-time is taking time to broaden his understanding of the world, with a particular focus on intensive care,” says Dr. Warrillow.
One of those research fellows who has crossed the world for the experience of working with Rinaldo is Dr. Neil Glassford.
“It would be easy to convey Rinaldo as a complex person, but he’s really a simple person. He’s a thoroughly decent man who just happens to be a genius, but at all times he’s able to convey that genius in a very human way that makes no-one else feel small,” Dr. Glassford says.
“It’s very humbling to see someone with his international profile standing at the end of the bed saying ‘I don’t know what the best thing to do is, there are no trials in this area’,” Dr. Glassford says.
“There are a lot of people walking around here who wouldn’t know his profile, because he’s not self-promoting,” says Helen Young. He is known as an extremely compassionate doctor: “A small boy had to comfort him once, when Rinaldo was crying because he hadn’t been able to save the boy’s father,” says research fellow Dr. Neil Glassford. “You see him sit down with relatives, and take the time to show them the patient charts or an ECG reading, and really make sure they understand,” says Ms Young.
Dr. Warrillow agrees. “He goes to extraordinary lengths to communicate with families. When a family is with Rinaldo, they’ll feel like they have his full attention and that there is no limit on his time. In that moment, they’re the only ones who matter. He assures them that no matter what the outcome is, he’ll be with them throughout it and will do everything he can for them. For those of us who were his students, he has provided the example of how to do it, and do it well.”
“He’s unusual for a professor of medicine: Rinaldo does the same proportion of clinical work as the rest of us – the same amount of on-call, night shift and weekend work as everyone else. There wouldn’t be another academic intensivist in the world who does that. He is the top of his game as a clinician. He is as revered for his clinical expertise as he is for his academic prowess.”
“His primary motivation is what is right for the patient.”
For Rinaldo, science promises solutions to humanity’s greatest sufferings, and a map to navigate our journey through the wonders of the human body, a territory that he describes as being “as complex as the entire universe and about which we know almost nothing.” Most specifically, it’s large-scale, randomised clinical trials – those that recruit thousands of patients and randomly assign them either the traditional management of a disease or the one being trialled – that he sees as the primary means by which he sees the practice of medicine becoming more precise, more effective, and less a stab in the dark.
Walking into Austin Health’s ICU, a white world full of high-tech machines punctuated by a soundtrack of beeps and pumping sounds, he says: “There is nothing in this place that is not the result of research!”
“When I started, we didn’t have MRI. Before we had cardio-pulmonary bypass, if you’d suggested stopping someone’s heart, people would have said you were insane. And it was probably the same when someone first suggested that you could put a balloon in people’s arteries,” he says.
“Do you think machines grow on trees? Everything here is human-made, evolved through a process of continuous improvement, step by slow, agonising step. Everything that we have to use in medicine today is thanks to the people doing research and the people who agreed to participate.”
As wondrous as it is to Rinaldo, the ICU is intimidating – terrifying even – to many of the people who are treated here, and their families. Understandably, many are reluctant to become involved in clinical trials.
“What we’re doing here is the pointy end of research,” he says. “We’re already giving people the best care possible - standard care, and then we see if we can improve care by adding one extra step. Before we begin a clinical trial in the ICU, there are animal studies, observations, and evidence builds up that there is a better way . Then it’s reviewed – by our colleagues, by funding agencies, by ethics committees – until we think ‘yep, this is a reasonable hypothesis, and introducing this might actually make things better’.”
“It’s when they don’t do research that they’re experimenting on you!”
“The truth is really difficult to discern. We can’t see it as individual doctors. It’s something that’s only possible to see by looking at the evidence from large, randomised clinical trials.”
“If you can persuade the world to change, you can save thousands of lives, and help millions of people for decades to come,” Rinaldo says. “There’s never an end to this. It never stops.”