Burn care pi­o­neer still go­ing strong at 88

Long re­tired from Army, S.A. doc­tor con­tin­ues to be in­volved in his field

Houston Chronicle Sunday - - CITY | STATE - By Sig Chris­ten­son STAFF WRITER sigc@ex­press-news.net

When Dr. Basil Pruitt be­came com­man­der of the U.S. Army In­sti­tute of Sur­gi­cal Re­search at Fort Sam Hous­ton in 1968, he be­gan a tra­di­tion that fel­low physi­cians, nurses and lab­o­ra­tory re­searchers came to dread: Satur­day “grand rounds.”

Pruitt went pa­tient to pa­tient at Brooke Army Med­i­cal Cen­ter with a team that in­cluded lab­o­ra­tory sec­tion chiefs — pathol­ogy, bac­te­ri­ol­ogy, hema­tol­ogy and oth­ers. Un­til Pruitt ran ISR’s burn cen­ter, the vis­its were on week­days. Lab chiefs were not in­volved.

“When I re­tired, the next Satur­day there were no grand rounds,” he laughed.

Pruitt, 88, is con­sid­ered the fa­ther of burn medicine be­cause of the ad­vances he helped pi­o­neer.

One of his most im­por­tant con­tri­bu­tions at the ISR, where he spent 27 years, was to dis­cover why burn wounds get in­fected. He teamed up with the late Arthur D. Ma­son Jr., chief of the lab­o­ra­tory divi­sion, who de­vel­oped and tested a burn cream on an­i­mals.

Their work led to a re­duc­tion in pa­tient mor­tal­ity and other im­por­tant clin­i­cal lab­o­ra­tory col­lab­o­ra­tions.

Fel­low physi­cians who worked for Pruitt say he was a piv­otal fig­ure in im­prov­ing the chances of sur­vival for the se­ri­ously burned, and for the con­fi­dence doc­tors now have in sav­ing even the worst-in­jured pa­tients. And it all be­gan back with those grand rounds.

“He’s a force of na­ture,” said for­mer Vet­er­ans Af­fairs Sec­re­tary James Peake, a re­tired three-star gen­eral who worked un­der Pruitt as a surgery res­i­dent and later com­manded BAMC.

Dr. Lee Can­cio re­called be­ing ques­tioned by the sci­en­tists and clin­i­cians in the hospi­tal’s mul­ti­dis­ci­plinary burn team, “maybe 25 peo­ple lis­ten­ing to what I, as a sec­ond-year surgery res­i­dent, had to say.”

“I had never be­fore seen so many peo­ple on morn­ing rounds,” said Can­cio, now the burn cen­ter’s civil­ian di­rec­tor and a re­tired Army colonel. “And I dis­tinctly re­mem­ber feel­ing very con­cerned about mak­ing sure that I got all the facts.”

Pruitt, long re­tired from the Army, hasn’t quit. He was in Bos­ton to ad­dress a con­fer­ence re­cently, main­tains a base­ment of­fice at Uni­ver­sity Hospi­tal, holds the Dr. Fer­di­nand P. Herff Chair in surgery at UT Health San An­to­nio and con­sults reg­u­larly for the ISR.

He pro­duced a moun­tain of in­flu­en­tial pa­pers on burns, the first of which ap­peared in the well-re­garded An­nals of Surgery in 1964. De­tail­ing mor­tal­ity in 1,100 con­sec­u­tive burns treated at ISR, it brought him recog­ni­tion as a clin­i­cian and re­searcher and set­tled the ques­tion of what area he would study.

“It told peo­ple that if you were a young adult in the United States at that time and got a 43 per­cent burn, not even half of the body sur­face, you had a 50-50 chance of liv­ing or dy­ing,” he said of the pa­per. “And that’s re­ally what con­vinced me that work­ing in the field of burn man­age­ment had a fu­ture be­cause the out­look was so bad that you could make a real im­prove­ment with ap­pro­pri­ate stud­ies to find out what to do.”

He re­mains the most cited re­searcher in burn care over the past half-cen­tury, col­leagues said.

“No one else had more peer-re­viewed pa­pers on burns than he did,” said Dr. Evan Renz, a for­mer BAMC com­man­der who led the burn cen­ter from 2008 to 2013.

“In 2014, we did the com­par­i­son. We looked to find the 100 most cited burn-re­lated ar­ti­cles over the last 50 years, and he led the pack,” Renz said. “He got peo­ple think­ing about things his whole ca­reer. He was a dom­i­nant thought leader in the area of burn man­age­ment and treat­ment for many years.”

But Pruitt is proud­est of his cham­pi­oning the mul­ti­dis­ci­plinary ap­proach to clin­i­cal lab­o­ra­tory re­search here, some­thing he be­lieves was re­spon­si­ble for the sig­nif­i­cant ad­vances in burn care that oc­curred on his watch.

BAMC the epi­cen­ter

The ISR burn cen­ter at Fort Sam — which re­ports to a dif­fer­ent com­mand from BAMC, though part of the same hospi­tal — owes its cre­ation to the atomic bomb, which drew the Pen­tagon’s at­ten­tion to the po­ten­tial for burn in­juries in com­bat.

Years af­ter Pruitt ar­rived for a two-year stint as a drafted Army doc­tor, Viet­nam and, later, Iraq and Afghanistan, brought waves of wounded troops to the cen­ter, the De­fense Depart­ment’s sole burn treat­ment fa­cil­ity.

The post-9/11 era has seen the largest per­cent­age of burn vic­tims of any U.S. con­flict: 1 in every 10 wounded. ISR also treats burned civil­ians, from South Texas oil field work­ers to Gov. Greg Ab­bott.

Their chances of sur­vival are high. That wasn’t the case when Pruitt started out.

“In those days, in many places, it was said you could find your way to the burn cen­ter just by the smell of rot­ting flesh,” said Pruitt, a 1952 Har­vard grad­u­ate who grew bored with ge­ol­ogy in grad­u­ate school there and en­tered Tufts Med­i­cal School. “When I ar­rived at the burn cen­ter, one of the things I saw was an ar­ti­fi­cial kid­ney be­cause of the his­tor­i­cal as­so­ci­a­tion

“He at­tracted amaz­ing tal­ent across the U.S. … folks who be­came in­sti­tu­tions in their own right.” James Peake, for­mer Vet­er­ans Af­fairs sec­re­tary

of acute re­nal fail­ure to mas­sive burns.”

BAMC be­came the epi­cen­ter for burn re­search in 1947, when the Army Wound Study Unit was moved from Halloran Gen­eral Hospi­tal to Fort Sam and even­tu­ally be­came the ISR.

Among the first of its many in­no­va­tions, it be­came known for the Brooke For­mula, which com­bined blood, plasma and a crys­tal­loid so­lu­tion of wa­ter, salt and trace el­e­ments.

A vari­a­tion of other for­mu­las dat­ing to 1943, it helped prevent kid­ney fail­ure, which killed one in every 10 burn vic­tims dur­ing the 1950s. It was a big step, but mas­sive swelling was a ma­jor draw­back of fluid treat­ment in those days.

“I saw pa­tients that were blown up and were huge, huge, huge, and gained all kinds of weight and had prob­lems with their lungs. Some peo­ple got so full of fluid that we had to open their ab­domen,” he re­called. “And now that’s a thing of the past, re­ally. It sel­dom oc­curs.”

Pruitt’s pa­per on a vari­a­tion of the Brooke For­mula, “He­mo­dy­namic Stud­ies of Burn Pa­tients Dur­ing Re­sus­ci­ta­tion,” spurred yet an­other de­vel­op­ment.

The Mod­i­fied Brooke For­mula cut fa­tal­i­ties to 3.4 per­cent of 1,809 pa­tients in 1970. Only 10 burn pa­tients out of 3,266 died of re­nal fail­ure from 1994 to 2004. To­day, he said, ISR uses a com­puter-as­sisted sys­tem that reads urine out­put and ad­just flu­ids every 10 min­utes.

As re­nal fail­ure was re­duced as a cause of death, Pruitt and oth­ers re­al­ized those suf­fer­ing from smoke in­hala­tion in­jury were at high risk as well. Around a third of all burn pa­tients suf­fer in­hala­tion in­jury, which in­creases mor­tal­ity.

Pruitt said he also be­came in­ter­ested in the patho­phys­i­ol­ogy of stress ul­cers in burns that in some cases cause mas­sive up­per gas­troin­testi­nal bleed­ing, and he co-au­thored a pa­per urg­ing physi­cians to em­ploy antacids or other forms of treat­ment. The prob­lem is “es­sen­tially un­heard of to­day,” he said.

Lots of pa­tients

How Pruitt set­tled on San An­to­nio is a tale rooted in what he calls the “doc­tor draft.” He was or­dered into the Army in the late 1950s while work­ing as a res­i­dent at Bos­ton City Hospi­tal. Doc­tors there sug­gested he do his Army ser­vice at BAMC be­cause of its fledg­ling burn cen­ter. He served two years, re­turned to Bos­ton but was dis­mayed to find that his old surgery depart­ment chair­man had moved.

“So I called the Army and said, ‘I think I’d like to come back if I could go back to the burn cen­ter.’ ”

San An­to­nio had about 588,000 peo­ple when he and his wife, Molly, set­tled here. The River Walk, a De­pres­sion-era cre­ation of the Works Progress Ad­min­is­tra­tion, wasn’t a glitzy tourism show­case — in fact, he was warned not to visit it af­ter dark. A sprawl­ing fu­ture city of 1.5 mil­lion wasn’t imag­in­able.

“You could go about four blocks from where we were liv­ing and be in a place where they shot doves at dusk,” said Pruitt, who lived on Fort Sam, a short drive from the old hospi­tal, now head­quar­ters for U.S. Army South. “Our kids all went to pub­lic school here. Mrs. Pruitt was elected to the school board for 24 years as a trustee.”

That was North East In­de­pen­dent School Dis­trict, where the Roo­sevelt High School li­brary is named the Molly Pruitt Li­brary.

Pruitt com­manded a com­bat hospi­tal in Viet­nam and later led the burn cen­ter dur­ing the war, which saw the worst-in­jured troops brought in by crit­i­cal care air trans­port flights staffed with sur­geons. ISR teams moved 824 burn pa­tients on 103 flights from Japan to San An­to­nio from April 1967 to De­cem­ber 1972. Only one died en route. It was no ac­ci­dent. “Un­der his lead­er­ship we part­nered with the Air Force to fly around and pick up burn vic­tims from all kinds of places, and if you think about it, it fore­told the kind of care in the “He was a dom­i­nant thought leader in the area of burn man­age­ment and treat­ment for many years.” Dr. Evan Renz, ex-Brooke Army Med­i­cal Cen­ter com­man­der air … this last 16 years of war (that was) so ef­fec­tive,” said Peake, the for­mer VA sec­re­tary. “We prac­ticed that with burn pa­tients.”

Dis­cov­er­ing that leav­ing a nee­dle or catheter in a vein too long leads to lifethreat­en­ing in­fec­tions that can reach or­gans, Pruitt said he and other re­searchers at ISR re­duced the prob­lem by chang­ing in­tra­venous lines more fre­quently.

But the “big­gest things,” he said, were the creams — “ef­fec­tive top­i­cal anti-mi­cro­bial ther­apy” that in­cluded Sul­famy­lon, de­vel­oped at the ISR.

“If you started Sul­famy­lon ther­apy im­me­di­ately upon ad­mis­sion of the burn pa­tient, you de­creased that in­ci­dence of in­va­sive burn wound in­fec­tion by 50 per­cent,” Pruitt said, adding that it also con­trolled the den­sity of bac­te­ria in the dead tis­sue so it could be more safely re­moved in surgery.

“Top­i­cal ther­apy and early ex­ci­sion to­gether re­duced … the pres­ence of in­va­sive in­fec­tion in those pa­tients who died. That is, they died of some­thing else,” he said. “It used to be that 60 per­cent of the pa­tients who died had in­va­sive wound in­fec­tion. It was de­creased to 6 (per­cent).”

It’s now less than that.

Well con­nected

As the U.S. pre­pared to drive Iraqi troops out of Kuwait in 1990, the Pen­tagon braced for a high num­ber of burn in­juries. Peake re­called that Pruitt had a built-in net­work of burn cen­ter di­rec­tors around the coun­try who could be tapped to help out.

Pruitt had trained many of them.

“He at­tracted amaz­ing tal­ent across the U.S. and academia … folks who be­came in­sti­tu­tions in their own right in terms of lead­ers and aca­demic surgery,” Peake ex­plained. “They came to study with Basil Pruitt. The burn unit had a rep­u­ta­tion of cut­ting-edge think­ing.”

Pruitt’s life­time re­search out­put to­taled 469 pa­pers in peer-re­viewed pub­li­ca­tions, 181 chap­ters in text­books, and 15 books and mono­graphs. Asked how many pa­pers he has writ­ten that proved to be turn­ing points in the field of burn care, Pruitt hes­i­tated.

“I don’t know,” he said. “A dozen, two dozen ma­jor pa­pers that in­di­cated a sig­nif­i­cant im­prove­ment in care.”

Those who cheered af­ter Pruitt re­cently re­ceived a Life­time Achieve­ment Award from BioMedSA, a non­profit that pro­motes health care and bio­science in San An­to­nio, might have won­dered if he was spend­ing his time va­ca­tion­ing with his wife or fish­ing in a quiet spot.

When Pruitt re­tired from the ISR in 1995 at the end of a 35-year Army ca­reer, he could have di­aled down his sched­ule. He hasn’t. As sec­ond vice pres­i­dent of the Amer­i­can Col­lege of Sur­geons, Pruitt was pre­par­ing for its con­fer­ence when asked if he was ready to shut down his of­fices at BAMC and Uni­ver­sity Hospi­tal and maybe write his me­moir.

He replied, with­out much con­vic­tion, “Yeah, yeah, I could do that,” and when asked again, replied, “Well, like I say, I’m giv­ing that some se­ri­ous thought.”

Jerry Lara / Staff pho­tog­ra­pher

Dr. Basil Pruitt spent 27 years lead­ing the U.S. Army In­sti­tute of Sur­gi­cal Re­search in San An­to­nio. Fel­low physi­cians who worked for him say he was a piv­otal fig­ure in im­prov­ing the chances of sur­vival for the se­ri­ously burned.

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