David S. Warner, MD Courtesy of Duke Health, Durham, NC, with permission.

It is with great reverence and respect that I write to acknowledge the death of David S. Warner, MD, Professor of Anesthesiology, Neurobiology, and Surgery, Duke University, Durham, NC. Dr. Warner died on December 5, 2021, after a 20-month battle with cancer. He was 68 years old. Dr. Warner is remembered by the neuroanesthesiology community for his clinical, research, and education efforts, as well as his mentorship of many accomplished investigators. Further, he was a founding editorial board member of Journal of Neurosurgical Anesthesiology and the 21st president of the Society for Neuroscience in Anesthesiology and Critical Care (SNACC).

I was fortunate to have many conversations with Dr. Warner during his illness, and portions of those are reflected within this tribute. Further, Dr. Warner was able to read and approve of this accounting before his passing. Thus, we can be assured of the accuracy and authenticity of the information.

David Warner was the son of an Episcopal priest (and later bishop) and moved many times during his childhood. He attended the University of Wisconsin, Madison, where he received a Bachelor of Arts degree in psychology in 1976 and a Doctor of Medicine degree in 1980. Upon medical school graduation, he moved to Iowa City, Iowa, where he initially was a resident in the University of Iowa Department of Neurosurgery. At this time, he knew very little about anesthesiology, in part because he had skipped attendance at his medical school’s anesthesiology lecture series. Later, as a neurosurgery resident, he was forced to take a 2 month-long rotation in anesthesiology and—as he recounted to me—“To my complete surprise, I found that I was immediately drawn to the personalities of the anesthesiologists and their love of using core principles in physiology, pharmacology, and anatomy to solve problems daily.” After 1.5 years of neurosurgery residency, he transferred to the Department of Anesthesia, a move that he described as “a match made in heaven.” He had no idea that he would someday become an academician, although he enjoyed visiting the laboratory of Martin D. Sokoll, MD, who had both laboratory-based and clinical-based neuroanesthesiology research efforts. Amusingly, many years later, Sokoll and Warner, as fellow members on the Iowa faculty, would co-author 5 original research articles.

Upon completing his residency, Dr. Warner had plans to enter private practice anesthesiology, but the new Department of Anesthesia Chairman, John H. Tinker, MD, thought otherwise. Without informing Warner, Tinker consulted with colleagues John D. Michenfelder, MD, of Mayo Clinic, and Petter A. Steen, MD, PhD, of the University of Oslo, Norway, and decided that Dr. Warner should study for a year with Bo K. Siesjö, MD, PhD, Director of the Laboratory of Experimental Brain Research at Lund University, Sweden. At the time, Siesjö was widely considered the world’s foremost authority in brain metabolism. Tinker secured the arrangements with Siesjö, and only then informed Warner that he would not be entering private practice in the United States but instead traveling abroad to study neuroscience. In reflection, Warner told me he considered himself an “innocent bystander” in the arrangements.

In Lund, Warner joined forces with not just Siesjö, but also a host of other prominent and developing neuroscientists who were exploring cutting-edge concepts and developing new biological models to evaluate metabolism in either normal or ischemic brains. Fortunately, the models readily lent themselves to the study of anesthetic effects on the brain. It was a very productive relationship that extended well beyond the single year, as Warner later made many additional brief trips to Lund to work on his research.

While Warner was engaged in activities in Lund, Tinker recruited Michael M. Todd, MD, of the University of California, San Diego, to join the Iowa faculty. Warner’s first reaction to learning of Todd’s impending move was, “I found it amazing that someone as accomplished and famous as Todd would leave his successful West Coast operation to come to Iowa.” Warner returned to Iowa shortly before Todd’s arrival. According to Warner, “In the beginning, he (Todd) was very much the mentor and I was the mentee, and I conducted my research in a corner of his laboratory.” At the time of Todd’s move, Todd and John C. Drummond, MD, both of San Diego, had formed what was arguably the most iconic brand in neuroanesthesiology research and education of that era. Few could have envisioned that someday the Todd-and-Warner brand would achieve that same regal status.

In Iowa, Warner introduced or developed small animal models and new measurement techniques to complement Todd’s previous and ongoing use of larger animal models of central nervous system function. Collectively, they were able to explore the anatomy, physiology, and pharmacology of the normal and ischemic brain. Further, they joined forces to perform complementary human studies that, in turn, greatly enhanced physicians’ and scientists’ understanding of the brain during anesthesia, neurologic surgery, and ischemic neurological insults. Portions of these studies challenged what, at the time, was the central anesthesiology dogma of cerebral protection by anesthetics and hypothermia: that is, that any protection was almost solely the result of depression of supply/demand metabolism, and metabolic depression could be assumed to be co-equal to protection. They were not alone in their suspicion of the dogma, but they certainly were in the minority at the time, though their non-centrist views were later vindicated.

Warner greatly respected Todd as “an idea machine,” and their mentor-mentee relationship and later collaborator relationship proved exceedingly rich. Among other activities, Warner helped organize, and was a founding member of and regular participant in, the annual Unincorporated Neuroanesthesia Research Group (UNRG), begun by Todd at the University of Iowa. The UNRG would later become the International Neuroanesthesia Research Group (INRG). This organization was initially envisioned to provide young, aspiring neuroanesthesiology researchers a forum to discuss with like-minded individuals their new and evolving research ideas in a minimally structured meeting format. The meeting changed locations annually and, at one such meeting in Banff, Alberta, Canada, Todd introduced the idea that there should be a human trial, directed by neuroanesthesiologists, to evaluate the efficacy of the burgeoning intervention of induced mild hypothermia to protect the brain during surgery. Such was the origin of the early discussions, and preliminary recruitment of investigators, for what would later become the Induced Hypothermia for Aneurysm Surgery Trial. In this research, Todd supervised the overall operations, and Warner, now at another institution, served as the Physician Protocol Monitor and immediately reviewed the data from each new patient to look for (and remediate) shortcomings in protocol execution.

Elsewhere, Dr. Warner was active as a presenter at national and international anesthesiology and neuroscience meetings, and he continued to mentor many research fellows from the United States and around the globe. In 1991, he was elected SNACC secretary, and by 1994 had progressed to SNACC president. At that time, SNACC’s annual meeting and business plan were managed by Phenix Corporation of Richmond, VA. Within weeks of assuming the SNACC presidency, Dr. Warner was notified that state and federal law enforcement authorities in Virginia had discovered that the executive director of Phenix had embezzled millions of dollars in funds from many professional societies under Phenix management. Several of these societies were much larger than SNACC and the overall sums of money they lost were much larger than the SNACC loss. However, the SNACC loss was, at first impression, devastating. Not to be defeated, Dr. Warner immediately formulated a working group of the SNACC president-elect and immediate past-president to find a new management arrangement to keep SNACC alive. This resulted in Ruggles Service Corporation agreeing to accept SNACC management on a pro bono basis until the organization could get back on its feet. The elegant catered lunches at the former annual SNACC meetings were replaced with box lunches of cold sandwiches, which—in an act of pride and defiance—became a badge of honor for SNACC members. One cannot overstate the importance of David Warner’s composure and courage in ensuring that SNACC survived and thrived, which indeed transpired over the ensuing years. Another focus of Warner’s leadership activities was in ensuring that international academicians were well represented in SNACC, not just as members, but also as leaders, including officers. As such, the rich diversity of leadership at SNACC today is marked with Dr. Warner’s fingerprints.

For many years, Warner served as the Journal Club section Editor for Journal of Neurosurgical Anesthesiology and the Neurosurgical Anesthesia Section Editor for Anesthesia and Analgesia. In addition, he served as Executive Editor for Review Articles and for Classic Papers Revisited for Anesthesiology. He was Basic Science Section Editor for Neurocritical Care and served as a referee for 37 journals.

After a decade on the faculty at the University of Iowa, Dr. Warner was invited by Joseph “Jerry” Reves, MD, to serve as a Visiting Professor at Duke University and a consultant on formulating a greater academic neuroanesthesiology presence at Duke. At the time, Duke had established excellence in neurology, neuroscience, and neurosurgery research, but not in neuroanesthesiology, and Reves was keen to change this. Much to Dr. Warner’s surprise and that of the worldwide neuroanesthesiology community, Warner soon thereafter left Iowa to pursue his future at Duke. Within a few years after his arrival, he was able to establish academic excellence in neuroanesthesiology at Duke and made sure that the investigational efforts were coupled to progressive clinical care, responsibility to the outside academic world, and the training and mentorship of young academicians.

At Duke, Warner quickly formed a productive relationship with Robert D. Pearlstein, PhD, a bioengineer in the Department of Neurosurgery, and later Huaxin Sheng, MD, a researcher in the Department of Anesthesiology who, among his many talents, had expertise in studies of transgenic mice. Together, these 3 individuals, joined by others, developed new methods and models (including cortical cell cultures, brain slice preparations, and transgenic mice models) for evaluating complex scientific problems, and they published dozens of original research articles together. Although some of this work was a continuation and refinement of some of Warner’s earlier research themes, other portions were new. Late in his academic career, and continuing until the end, he performed pioneering work on the neuroprotective effects of superoxide dismutase and other antioxidants, which showed progress in animal models of subarachnoid hemorrhage-associated vasospasm and cerebral ischemia. A 2004 review article, entitled “Oxidants, Antioxidants, and the Ischemic Brain,” based in part on this research, has now been cited more than 400 times.

Dr. Warner fueled his research and training of research personnel at the University of Iowa and Duke University with grants from the American Society of Anesthesiologists, the American Heart Association, and industry, in addition to 30 grants from the US National Institutes of Health. Remarkably, at the time of his death, he had received 33 years of continuous funding from the National Institutes of Health. There are few individuals in the field of anesthesiology, regardless of the subspecialty, who can attest to such a record.

For his many accomplishments, Dr. Warner was honored with the American Society of Anesthesiologists Excellence in Research Award in 2005 and the SNACC Distinguished Service Award in 2011. And in 2012, the greater Duke University bestowed upon Warner an endowed professorship, the Distinguished University Professor of Anesthesiology, which Duke University has described as “one of the highest honors in academia.”

Outside of work, Dr. Warner loved his trips to Hawaii to vacation (he took more than 50 such trips), and he loved sailing on the North American Great Lakes. He and his wife owned a second home on Wisconsin’s Door County peninsula, and he kept a 33-foot sailboat, the Hurrah!, there. In 2017, his daughter gave him a coaching video on becoming a long-distance runner, an activity that Dr. Warner had never done before, but immediately came to adore. On Saturday, March 7, 2020, he ran 21 miles in anticipation of his first marathon race 2 weeks later. However, this plan was never realized. Instead, within those 2 weeks, the race was canceled due to the new-onset COVID pandemic, he suffered an acute neurological event, and a magnetic resonance image of his brain revealed a right temporal lesion with a mass effect. Instead of crossing a marathon finish line on Saturday, March 21, he instead was awakening in an intensive care unit a day after brain surgery to remove the tumor. He was given a diagnosis of brain cancer: glioblastoma multiforme.

Dr. Warner approached his diagnosis with realism, a sense of scientific curiosity, and a greater sense of spirituality. He was sequentially treated with the most progressive treatments that surgical-, medical-, and radiation-oncology could offer, but he knew that the eventual outcome was inescapable, telling me in July 2021, “It is clear as a bell; I’m dying.” He became more active in his Christian prayer group, based in Hawaii and whose meetings were completed via the Internet, and he shared his feelings and perspectives with family and close friends. I was one of the beneficiaries. He observed his treatments and progression of neurological infirmities with the attentiveness one would expect in a mature neuroscientist and life-long learner. He had tremendous respect for the clinicians who cared for him and the manner in which they used a multidisciplinary, evidence-based approach to his treatments and prognostication. He shared with me that his prayers became more meaningful and richer to him and were focused on thanksgiving. Any prayer requests were reserved for others.

Although Dr. Warner was tremendously accomplished as an individual academician and scientist, he took great pride in his affiliations and relationships with other neuroanesthesiologists and neuroscientists and celebrated their collective accomplishments, locally, nationally, and internationally.

David Warner, MD, will be missed by many as a friend and shining light in the world of neuroanesthesiology and neuroscience. He had a clear head and a pure heart, and he exemplified the type of person we all should desire to be. He lifted up those around him, and he enjoyed basking in the spotlight-reflections off of his mentees, collaborators, and friends. He is survived by his best friend and wife of 41 years, Rose Warner; a daughter, Lindsay Warner, DVM; and a son, Seth Warner. Members of our neuroanesthesiology community are encouraged to keep Dr. Warner and his family members in your thoughts and prayers in the times ahead.

William L. Lanier, MD Mayo Clinic, Rochester, MN [email protected]