Deep Heat

After some 50 years, Basil Pruitt rules the field of burn surgery through his vision, grit and leadership

David Jayne, then 30 years old, was mapping the terrain in Guatemala for an international geodetic survey in 1959 when his gas tank leaked and the helicopter he was piloting exploded and rolled over. He was burned across 65 percent of his body, and wasn't transported to San Antonio's U.S. Army Burn Center until two weeks after the accident.

By the time he arrived, Jayne had gangrene on his hands and face. Basil Pruitt Jr., '57, was a staff surgeon at the burn center, where Jayne had 29 operations and spent three-and-a-half years on and off. Miraculously, the pilot went back to flying helicopters for eight more years. In 1970, Jayne retired in his mid-40s to attend law school and start his second career, where the San Antonio attorney became known for representing burn survivors. His path and Pruitt's have crossed again and again.

"Colonel Pruitt, as I like to call him, and other burn doctors who worked with him were instrumental in my recovery," Jayne says. "He is the most revered burn doctor in the world. I've seen it firsthand from him working on me and then from other things I have witnessed over the last 40 years. I have observed his quiet demeanor, his knowledge and his ability to instruct other doctors and lay people in the treatment of burns. He had the ability to size up a situation and to quickly disseminate the information to the other doctors on rounds. He quickly and quietly was able to ascertain the problem and make recommendations, which often meant performing surgery."

Regarding the scale of Pruitt's fame, Jayne recalls attending a conference at the National Institutes of Health where Pruitt was asked to speak: "There were more than 300 doctors from almost every continent, and they hung on every word he had to say. They crushed him after each speech with questions, and he couldn't break away for 30 to 40 minutes."

ON THE MOVE

If you want to reach Pruitt at home, it helps to be nocturnal. That is because six days a week, including Saturday, the internationally renowned burn surgeon is at his office by 9 a.m. at the University of Texas Health Science Center at San Antonio, where he is a clinical professor of surgery and edits the Journal on Trauma. He doesn't return home until 10 or 11 p.m. "You can call me in the evening when I get back," he tells a reporter cheerfully. "I'm up late!"

That is, when he's even in town. Between accepting every imaginable award in and around the world for his surgical skills and scholarship, lecturing and speaking from Taipei to Cairo to Ankara to Buenos Aires, being a member of 38 professional societies, presiding as president- elect of the Shock Society, attending meetings as a senior member of the American Board of Surgery, and often conducting rounds at the U.S. Army Burn Center at Brooke Army Medical Center, Pruitt's plate is as full as they come.

As editor of the Journal, he receives a staggering 1,600 to 1,800 academic papers a year. Pruitt looks them over, assigns three reviewers per article, studies every review, makes comments and sends them back to the author for revisions. Once they're resubmitted, he farms them out again, and studies those comments before editing the piece. "I read thousands and thousands of reviews a year," he notes.

An equally prolific writer, Pruitt has authored or coauthored 444 papers and 170 chapters in major textbooks (including several editions with his older son, Scott, an associate professor of surgery at Duke, and another with son Jeff, an assistant professor of radiology at Southwestern Medical School). "I have some others cooking," he mentions casually. If you want to read Pruitt's bio, which lists his awards, honors, lectures, presidencies, scientific review groups and work experience, make sure you have plenty of time-it runs 82 pages. You will see that he has served on 11 editorial boards alone.

Throughout his career, he has conducted clinical and laboratory research that has dramatically improved the treatment of burns, and he has published papers in all areas in which advancements have been made. Three developments in particular-the immediate administration of fluids, inhalation therapy to treat damaged lungs and an antimicrobial cream that prevents infection-have significantly slashed the mortality rate of burn patients, and Pruitt has worked on all of them.

Which means that the buzz-cut Pruitt is to burns what Mick Jagger is to rock 'n roll: a legend. He has been instrumental in discovering and implementing stunning advances in burn care that have sliced the mortality rate for victims since he first entered the field. Elected president of 10 surgical or burn associations, he has mentored and influenced other eminent burn physicians. Imagine this: In the U.S. Army Burn Center, a bronze bas relief of Pruitt stands in tribute to his achievements.

While many of his classmates have retired or are winding down their medical careers, Pruitt seems to be revving his up-if that is possible. Consider his peripatetic schedule between January and June of this year:

• A meeting in Vail for the North American Burn Society (he's past president)
• On to Phoenix to meet with members of the American Association for the Surgery of Trauma (past president)
• Fly to Sanibel, Fla., to present a report to the Eastern Association for the Surgery of Trauma
• Make a Saturday night stop in Indianapolis to attend a dinner for the American Surgical Association (past president)
• Home to San Antonio for two days
• Off to Washington, D.C., for an American Burn Association conference (past president) and to meet with members of Congress
• Back to Phoenix to receive the illustrious Society of University Surgeons' Lifetime Achievement Award
• On to Maui to present a paper relating to the equally eminent Tanner-Vandeput-Boswick International Burn Prize he was awarded last September
• Take off for Steamboat Springs to present a report to the Western Trauma Association
• Fly to Wayne State University and then Louisiana State University to lecture
• Travel to San Diego for an American Burn Association meeting
• Grab a plane to Philadelphia for a visiting professorship at Temple University
• Go to Toronto for the Surgical Infection Society conference (past president)
• Fly to Colorado Springs for an American Surgical Association meeting
• Be in Buffalo to receive the renowned Roswell Park Medal and then fly to Boston for his 50th Tufts medical reunion
• Off to lecture at the University of Southern California
• Attend a Shock Society (president) meeting in Baltimore
• Teach at Stony Brook Health Science Center in New York

Get the picture? It doesn't look like there's much more room on that proverbial plate.

Early in June, Pruitt has his wife's 55th reunion at Mount Holyoke, and he has his 55th from Harvard College. "I hope I don't have a conflict," he laughs.

A HOT CAREER

Drafted into the Army during his residency in 1959, Pruitt spent 35 years serving Uncle Sam, the last 27 as commander and director of the U.S. Army Institute of Surgical Research's (USAISR) burn center. In 1995, he retired from the Army, but not from medicine. Besides being a clinical professor of surgery at the University of Texas, he holds a similar appointment in Bethesda, Md., at the Uniformed Services University of the Health Sciences, the only government medical school in the country. At age 77, Pruitt does not operate much these days, but still has operating privileges and from time to time scrubs with residents or treats problem wounds.

Remarks from colleagues regarding his two most recent prizes provide insight into his wide-ranging medical contributions. Introducing Pruitt at the Tanner-Vandeput- Boswick Burn Prize ceremony in Brazil, the speaker told of his early appointment as chief of the Burn Study Branch and then commander and director, both of the USAISR.

"During his tenure, the USAISR became a model of burn care, education and productive research," the presenter commented, mentioning Pruitt's "prestigious eponymic lectureships," awards, visiting professorships and association presidencies. The audience was informed that Pruitt's "greatest and enduring legacy is the mentorship of a cadre of physicians who have become leaders, not only in burn care and research, but also in the broad field of medicine. The list includes 10 past presidents of the American Burn Association, 45 directors of burn centers and units in the United States and abroad, 17 departmental chairs and the current president of the International Society for Burn Injuries."

Pruitt's other "superstar" honor is the Society of University Surgeons Lifetime Achievement Award; he is just the third recipient of the prize. The letter notifying him read: "You have been a great supporter and a superb mentor for so many young academic surgeons. Your steadfast commitment to both clinical and basic research has been truly incredible, and you have set the standard for so many of us in terms of what it means to be a surgeon-scientist."

William Cioffi, currently chairman of the Department of Surgery at Brown Medical School, who was at the U.S. Army Burn Center with Pruitt, agrees: "Basil always surprised people with his knowledge about various aspects of complex basic science. And he's the kind of guy who engages everybody in the process-on the burn unit, in patient care and through education and research. He has a way of taking those three disparate groups and getting everyone interested in the same problems. Basil has leadership skills-the ability to engage the entire team in the process and inspire people."

Arthur Donovan,'48, who taught on the Tufts faculty before retiring as chairman of surgery at the University of Southern California, knew Pruitt during his Boston City Hospital days. He attributes his colleague's stellar career to his "probing and incisive intellect. Because of this, he has been extremely productive in the areas of research in burns, infection, trauma and surgical metabolism. He also has a willingness to give unstintingly of himself."

WHY BURNS?

Burns weren't always Pruitt's field of interest. After graduating from Harvard College in 1952, he spent a year at his alma mater's graduate school pursuing a master's degree in geology. But then, just one course shy of his master's requirements, he opted for medicine at Tufts instead. "I decided I was more interested in the life sciences than in scratching rocks the rest of my life," he recalls. Still, he did gain a gem that year: a student in his geology program introduced him to her college classmate, Molly, now his wife of 53 years.

Pruitt left Harvard to enroll at Tufts, and has had no regrets. It was while interning at Boston City Hospital that Pruitt was introduced to the field of burns as well as to the Army-two areas that became lifelong passions. "It just seemed to me that burn patients had so many problems, and there was a disturbance of so many organ systems that you could always find something that would be exciting to work on," muses Pruitt.

As a medical student, the 6-foot, 2-inch Pruitt, like all physicians in training, was subject to the government's Berry Plan, which was a draft for doctors. Established during the 1950-53 Korean War, the Berry Plan (named for Frank Berry, the assistant secretary for health affairs) allowed physicians to be deferred from military service while they trained in civilian medical hospitals. They could then use those specialties during military service.

In that era, most new M.D.s were drafted right after their internships to serve as general medical officers or at troop clinics. Pruitt received a partial deferment and was able to finish a surgical internship and his first year of a surgical residency. On a cardiothoracic rotation, he met a CT fellow named Harry Soroff who had just spent two years fulfilling his Army requirement at the San Antonio Burn Center. He told Pruitt he thought it might appeal to him, too.

Yet, when it came time to decide where to serve his country, Pruitt's approach was a bit unorthodox. That is, he had been reading The New York Times Sunday travel section and came across an article about Taiwan. The piece said it was a wonderful place to visit, and because it was also one of the choices for Army assignments, he impulsively checked it off. "It sounded so great. But there was just one position, and I didn't get it," Pruitt recalls. His second choice was the burn center in San Antonio. "They picked me, and that determined the rest of my professional life," he explains.

It was 1959, and Pruitt was 29 years old. As a draftee, he was obligated to a two-year stint. After he completed it, Pruitt returned to Boston to finish up his residency. But when he went back to Boston, he found the people under whom he had trained had left, and the program was disappointing. So the young physician called the Army and asked if he could finish his residency with them. He was accepted as a fourth-year surgical resident at Brooke Army Medical Center in San Antonio. In 1964, after completing his Army residency, Pruitt was reassigned to the burn center as a staff surgeon; one year later, he was promoted to chief of the Burn Study Branch.

Pruitt's professional journey was to take even more interesting turns. While working at the burn center, he participated in the air transport of soldiers wounded in Vietnam. About once a month, he would leave Texas on a Friday, arrive in Tokyo on Saturday, drive to an Army hospital (a former Japanese military compound during World War II) in Yokohama to examine the injured brought from the Vietnam battlefields, make sure they were stabilized, and then Monday, take them back to Texas for treatment. The injured, along with Pruitt, would be whisked via helicopter from Yokohama to a U.S. Air Force base; the wounded were loaded onto litters stacked three high for the flight home. "It was a great accomplishment. We transported hundreds of patients, and only lost one in flight," he says.

Next, Pruitt was informed that he was being sent to Okinawa and was given less than 24 hours to pack for what would be a four month surgical stint. After a year back at the burn center, he was asked to run the burn unit in Yokohama, but Pruitt was interested in an academic career and was advised against it. "I was told that if I spent three years or so in Japan, I'd fall out of academic circles, and nobody would hear of me," he remembers. "Instead, I was encouraged to go to Vietnam, put in a year as a combat surgeon, and that would establish my military credibility so then I could go on with academics at the burn center."

Pruitt listened to the advice and declined the Yokohama invitation. In 1967, he headed to Vietnam, where he was appointed chief of professional services at the 12th Evacuation Hospital. At the busiest hospital in Vietnam, Pruitt saw a daunting 400 to 500 major cases a month. In the latter months of his Vietnam tour, he was chief of the Trauma Study Section of the U.S. Army Medical Research Team (Vietnam).

STAR TREATMENT

During the course of his career, Pruitt witnessed major changes in burn treatment and played a tremendous role in those changes. "What we've accomplished is really quite remarkable," he reflects. "When I first came to the burn center, the minute you walked in the door, you could literally smell the burn center. There were many infected wounds with dead tissue hanging around, and now the ward has no distinctive smell. It's like any other hospital ward."

The first significant change in burn care came with the discovery that timely administration of fluids can eliminate acute renal failure. It used to be that one in 10 burn victims died of kidney failure. "Now burn shock is a thing of the past," Pruitt declares.

The next exciting advance involved inhalation injury, an inflammation of the airways and the lungs caused by the chemicals in smoke that is inhaled-which, at the time, was a major cause of death in burn patients. "First we identified the fact that inhalation injury could increase mortality by an amount equal to another 20 percent of burn injury," he says. (In other words, a patient with a 40 percent burn with inhalation injury suffers the likely death rate equivalent to that of a 60 percent burn.) "We developed a model and found that high frequency interrupted flow positive pressure ventilation (HFIFPPV), a system of improving ventilation of the injured lung, significantly reduced the occurrence of pneumonia and improved survival," he explains.

The biggest revolution in burn treatment has been in wound care. In 1966, the San Antonio Burn Center developed a special cream that prevents infection in the burn wound and the spread of bacteria to other tissues. The cream penetrates dead tissue and prevents microbial proliferation, allowing the burn tissue to be excised without causing generalized inflammation. (If you cut away dead tissue without using the cream, the patient could go into shock.)

In the past, 60 percent of patients who died at burn centers did so from invasive burn wound sepsis. That figure shrinks to 30 percent with topical therapy and then 6 percent when you use the cream and surgically remove the burn tissue, and these days, that number has plummeted to 2.3 percent.

There are other advances in burn care, including improved dressings and membranes to cover the wound. The ideal coverage, for instance, for third-degree burns is a patient's own skin. But what do you do if there's an 80 percent burn? Where do you get that skin? Physicians sometimes use another human skin, but that is always rejected (unless it's from an identical twin), and the wound must be closed with the patient's own skin. Currently, there are techniques to take a massively burned patient's skin when he first arrives at the hospital, expand those cells in tissue culture, and then apply sheets of those cells to the excised wound. Researchers are scrambling to develop other forms of culture derived membranes.

Yet another critical breakthrough has been identifying and characterizing the endocrine and other physiologic changes that boost a burn patient's metabolic rate to dangerous levels. While at the burn center, Pruitt helped develop techniques to minimize physiologic stress and meet the nutritional needs of patients. (If you reduce heart function through medication, you could impair wound healing.) What Pruitt and the burn center staff discovered is that if a burn patient receives enough calories and proteins to match his elevated metabolic needs, it prevents auto-cannibalism, preserves body mass and hastens recovery. "That means our patients are no longer discharged looking like they have survived Dachau," says Pruitt.

Today, active areas of research include exploring other ways to combat infection. For example, one of the changes that occurs following a severe burn is immunosuppression. So researchers are evaluating using drugs to improve the function of the cells in the immune system, or employing low-amperage direct current to control infection and accelerate wound healing.

"All of these developments in burn care have occurred since I first started," notes Pruitt. One of the first papers he wrote, in fact, during his time as a draftee, concerned burn mortality. "At that time, a young adult 15 to 40 years old who had a 43 percent burn had a 50-50 chance of living," Pruitt says. "Today, that young adult with an 83 percent burn has a 50 percent chance of living. That is real progress."

NOT SITTING STILL

Both Pruitt and Jayne, the former helicopter pilot, remain tireless advocates for burn survivors. Jayne retired from law in 1995, and soon after, he and his wife formed a foundation called the Texas Burn Survivors Society (TBSS). The nonprofit offers financial and psychological support to hospital patients as well as to those who have been discharged. Many of the society's referrals come from Pruitt's old stomping ground, the burn center.

Burn survivors have unique needs, which Jayne has addressed. For example, painful treatment may be ongoing for years, and children with physical scars may be taunted or gawked at, making psychological healing difficult. Survivors often lose beloved family members and their home in a fire; the cost of recovery can be prohibitive and wipe out a family financially.

Therefore, TBSS' Basil Pruitt Fund, as it is called, provides emergency financial assistance to critically burned patients and their families, including food, clothing, shelter, transportation, utilities and basic necessities. The organization also picks up the tab for therapy sessions for family members and medical items not covered by insurance, such as special splints. Jayne's nonprofit also runs a free camp for burn survivors ages 5 to 17 and their siblings, as well as for children of burn survivors.

When he's not publishing, editing, traveling, researching, lecturing, collecting awards or mentoring, where is Pruitt? He may be at home with his wife, Molly, admiring the Japanese modern woodblock, stencil, lithograph and silkscreen art they have collected on their many trips to Japan. Or, since he's not one to sit still, he may be taking some art work down and moving other pieces around. "The house is full now," Pruitt explains, "and we don't have any more room on the walls, so we're rotating our art like a museum."

After some R&R at home, Pruitt inevitably will decide to head to his office to tackle yet another Journal review or pen another acceptance speech. These days, he has traded scrubs for the "Pruitt uniform": grey trousers, a blue blazer, tie and penny loafers-even on Saturdays. Of course it makes sense that the man who has a way with dressings would like to dress up himself.