Representatives of the U.S. military health system met Sunday for the Excelsior Surgical Society meeting, and a highlight of the daylong session was the fourth annual Army Major John P. Pryor Lecture by guest lecturer Basil A. Pruitt, Jr., MD, FACS, FCCM, MCCM, the Dr. Ferdinand P. Herff Chair in Surgery, clinical professor of surgery, department of surgery, trauma division, University of Texas Health Science Center, San Antonio; professor of surgery, Uniformed Services University of the Health Sciences, Bethesda, MD; and the Immediate Past Second-Vice-President of the American College of Surgeons.
The topic of the lecture, A Serendipitous Surgical Journey, was chosen “to illustrate how chance influences one’s career,” which is not always immediately obvious but becomes clear later, Dr. Pruitt said. He began by speaking of how Sir Alexander Fleming, FRS, FRSE, FRCS, by chance first saw the antibiotic properties of penicillin in 1928; from there followed a series of events that led to an understanding of how the medication could treat sepsis in burn victims and eventually the U.S. Army studying burns and treatment at Fort Sam Houston, San Antonio, TX.
Dr. Pruitt’s own “serendipitous events” led to him studying burns at the same institution, then to Vietnam during the Vietnam War as Chief of the Trauma Studies Section, and then after his tour to a position as Commander and Director of the U.S. Army Institute of Surgical Research (USAISR) at Fort Sam Houston. “In those days, a young adult in the military age group, 15–40, with a 43 percent [total surface area] burn was associated with a 50/50 chance of living or dying,” said Dr. Pruitt, noting that his inclination toward research and a desire to improve those poor survival odds led him down the path that would eventually transform the treatment of burns in both the military and civilian settings.
From his leadership position in the USAISR, Dr. Pruitt oversaw a multidisciplinary integrated clinical laboratory research program that led to four advances in burn care—two evolutionary and two revolutionary, he said. One of the evolutionary changes came in the area of fluid resuscitation, in which patients with extensive burns previously have an associated 9 percent occurrence of acute renal failure due to excessive administered fluids. Dr. Pruitt and colleagues readjusted the fluid formula and “essentially eliminated renal failure” from severely burned patients, with only 0.3 percent experiencing the condition after the development. The second evolutionary change came in the field of inhalation injury, where endoscopic diagnoses with fiberoptic bronchoscopes and the provision of positive pressure ventilation “reduced the occurrence of pneumonia and increased survival in patients,” Dr. Pruitt said.
One of Dr. Pruitt’s most significant contributions to the field of burn care came through a revolution in the understanding of how bacterial and microbial proliferation in a severe burn affects patients and a subsequent change in treatment. With the help of a resident pathologist, Dr. Pruitt and his team came to understand that “to the immunosuppressed, extensively burned patient, there is no such thing as a harmless microorganism,” he said.
The avascularity of burnt tissue meant that pathogens could spread from dead tissue to live tissue and eventually overwhelm an immunosuppressed patient. Animal models helped to determine that topical treatments, such a mafenide acetate, decreased bacteria counts to very low levels and, along with the concomitant ability to more safety excise dead tissue and graft healthy tissue, “reduced the occurrence of invasive burn wound infection as a cause of death … by 10-fold,” from a 60 percent occurrence rate to 6 percent.
The second revolutionary advance was in the understanding of the metabolic response to injury. Previously, the severely burned patient was thought to have a whole-body metabolic response, but Dr. Pruitt’s team found that the “metabolic response is wound directed, so one needs to meet these metabolic needs and not minimize the metabolic supply to that [area] by altering the blood flow or cooling the limb,” he said. These discoveries led to “full-service metabolic management” for extensive burns, which entailed an overhaul of nutritional and supplemental dietary intake, as well as pharmacological response.
Serendipity in a surgical career is often only recognized in hindsight, Dr. Pruitt concluded. But “one can optimize serendipity by enthusiastic performance.”