SAN ANTONIO (AP) - 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.”
The San Antonio Express-News reports 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 recently was in Boston to address a conference, 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 also led the burn center from 2008-13.
“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.
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 - one 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 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 came 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 that 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 co-authored a paper urging physicians to employ antacids or other forms of treatment. The problem is “essentially unheard of today,” he said.
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 that 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 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 around 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 the 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 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 life-threatening 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.
As the United States 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.”
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Information from: San Antonio Express-News, http://www.mysanantonio.com
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