Photograph by Stephen Seebeck
Dr. Brad Warner’s the first to show up for the 3 p.m. interview. He’s come straight from the operating room, wolfing down half a sandwich in the hall en route. “We used a piece of the colon to replace the esophagus,” he says. “Eight-year-old girl. She had a narrowing that was congenital. Food was getting stuck, and they would have to take her to the OR, pull out the food, and stretch her esophagus. They’d gotten to the point where they were doing that monthly.” Warner is surgeon-in-chief at St. Louis Children’s Hospital; his wife, Dr. Barbara Warner, is a neonatologist. She arrives a minute later. “Hi, honey,” Brad says, making his voice a squeaky chirp. He turns to me. “This is our Time Together,” he explains solemnly.
Do you two talk about your work at home?
Barb: We talk about everything at home!
Brad: Our daughters are like, “Do you have to talk about this again?” I was watching a YouTube video on how to do a laparoscopic pancreatectomy. Our daughter Emily couldn’t stay and watch. I said, “Isn’t this neat, Em? Look at that!”
So she’s probably not going into medicine. What about your other daughter, Lauren?
Brad: She thought she was pre-med; now she’s doing cognitive psych.
Barb: We’ll see. Life’s a journey.
Brad: And she’s cheering for Wash. U.
Barb: All I worry about is her falling on her head while she’s cheering.
Does treating seriously ill children make you a paranoid parent?
Brad: Oh yeah. When the kids were little and they were taking horseback riding, we saw some bad stuff, accidents with horses, and I just pulled them out of the class. But Lauren’s [he sighs] an adult now.
When you met, was it love at first sight?
Brad: Yeah.
Barb: Kind of.
Brad: She was a medical student, and I was a resident. I was having lunch with one of our faculty surgeons, and Barb came and sat down across the table. She had these big eyes.
Did you notice Brad when you sat down?
Barb: Yeah, he was kinda cute. He’s still kinda cute.
Brad: Then a couple months later, I was getting a soda, and she said, “Where’s M&M (the morbidity and mortality conference)?” I said, “Did you just start on surgical rotation?” Turned out she was on my team.
Barb: Yeah, but he didn’t ask me out until the end of my surgical rotation. [She starts laughing.] He asked while I was debriding a foot, with all this necrotic tissue…
Brad: And we slept together the first night we went out. ’Cause we went to the movies, and in five minutes, we were both asleep.
Barb: You think back to the early years...
Brad: I was so stressed.
Barb: We both were. Both of us came from very simple backgrounds. My parents were immigrants from Slovenia. You look at the life that you build, and there is a sense of accomplishment. We really did it all on our own—financially, clinically, academically…
Is your marriage easier because you’re both doctors?
Brad: Oh yes. We understand the stress, the time commitment.
Barb: Sometimes the families need you, and you just have to be there.
Brad: Also the amount of work that’s required. Barb says you come home to escape, but oftentimes you come home and you work. Each of us are usually at our computers writing, reading, or researching.
Yet you manage to raise two daughters, plus Hooper, your Weimaraner.
Brad: I think the reason it works is that she’s totally able to keep a handle on everything. She makes lunch for me every day, and she fixes it for the kids, and we have dinner together every night.
Barb: Sometimes at 9 o’clock!
Brad: Dinner together is something her parents felt was very important. I never would have thought about it. She has the capacity to do way more than I can. She can keep up with the kids and what’s going on at school. I’m a typical guy: You tell me next Friday at 2 o’clock and it’ll be 2:50 and I’m saying, “What?”
Barb: [Laughing.] I’m a neonatologist. You need attention to detail.
Brad: That makes a big difference, someone who gets it, and who gives me all the slack in the world.
Barb: We give each other a lot of slack. You just totally have to say, “It’s OK.” And have a sense of humor. [She smiles ruefully.] When the kids were younger, very few of his colleagues had wives who worked full time in medicine, so he had more responsibility than they did.
Brad: You resent that—at least I did, for a while. My colleagues would come home and put their feet up, or play with the kids. Barb would say, “I’m on call. Here’s the baby; she needs to be fed. I’ve gotta go.” But it forced me to be more a part of our daughters’ lives, and I wouldn’t trade that for anything in the world. Also, it made us partners, because we really depended on each other.
How long have you lived in St. Louis?
Brad: We came here four years ago.
Barb: And I love my job—put that in there!
Brad: Well, that is not to be ignored. We came here for the job.
Barb: It’s a great children’s hospital. It really is world-class. And I really like having his family here in town.
Brad: I grew up here, kindergarten till ninth grade, and then my parents split and I moved back for part of high school.
Barb: We were out yesterday and called his mom—she usually comes over for dinner Sunday nights—and she wanted us to come see the bathroom she’d just painted.
How often do you overlap, so you’re both either treating or operating on the same patient?
Brad: Probably five or six times a year.
Barb: If you are surgeon of the week, they will be my surgical patients.
Brad: Especially some of the diaphragmatic hernias—they have holes in the diaphragm.
Barb: [She pats his arm.] And I stay up and take care of them for him.
What cases brought you great joy or still haunt you?
Barb: Remember the baby that was at death’s door?
Brad: That was a diaphragmatic hernia. Those can be really hard. They just don’t read the book you read in med school, those babies. Sometimes I look at them and say, “OK, tell me what’s next.” They take you through the mud. And sometimes they don’t do well.
Barb: The hardest are always cases where you think you can pull them through, or you are so hopeful you can pull them through, and then it turns around.
Brad: I had a kid die on the table on me. A 12-year-old kid, from a shotgun blast. It completely blew apart major blood vessels in his abdomen and pelvis. We got him back briefly, but there was just too much damage. The family had no clue how bad things were. For me to walk into the waiting room and tell them—
Barb: But there are good things too, like in the nursery, where you have these extremely preterm infants. We do follow-up clinic, so I saw a set of triplets that were extremely premature—two boys and a girl—and they’re 3 years old now. The boys look fabulous, neurodevelopmentally. Certainly the girl has challenges, but she is just a spitfire, and her brothers just egg her on. We discharged them from the clinic, and we almost all started crying. You feel like you have been on a journey with them. You have.
You face, every day, the toughest question: Why do innocent children have to suffer?
Barb: We see a lot of bad things happen to complete innocents. I think that there’s a natural biology, and that things happen within that natural biology. I also feel that it can certainly be for reasons we don’t understand. I have seen great growth in people who have undergone great hardships; I’ve also seen families torn apart. Do I believe in destiny or that all things are for a reason? I think you probably do. [She looks at Brad.]
Brad: Mmmhmmm.
Barb: I think I don’t believe that as much.
Brad: I think when a child is born, that’s an absolute miracle. I also view death as a miracle. The saddest thing of a death is the loss for someone else, but in my mind, at some point, maybe they will reconnect, and there was a reason for that encounter. Barb and I have both been in these situations where babies are born and they are only here for a short time. But a day of life or 100 years, there’s no less impact on someone’s life.
What keeps you going, during the stress and sadness?
Barb: Having a home to go to where you can feel safe and supported, and looking forward to going there. There were some times I was really stressed last spring, and to just have that safe place, where it doesn’t matter if you feel like you didn’t do your best or things didn’t go like you hoped they would—either clinically or you didn’t get the grant, whatever. That is not what makes you you at home. At home, it’s unconditional. It would be really hard to do this without having that.
What do you notice about how infants react to pain?
Barb: When we started, pain medication was a whiskey nipple.
Brad: I see the physical effects of pain on an infant. The heart rate goes up…
Barb: Now, we monitor pain very closely. What the life effects of trauma are, it’s harder to sort out. It’s a whole different environment, being in the NICU. What we ask of parents!
Brad: We sometimes look at each other and say, “Geez, if we ever had to go through this…”
Do people ever say, “Why keep babies alive when they will have extreme challenges?”
Barb: Yes.
Brad: It’s more on the flip side, I think. We recognize the limitations of what we can do, and with most families, it’s counseling them on when it’s enough. I always say, “We will let you know when we are not doing things for your baby, we are doing things to your baby.”
Barb: Most of the time, there is no right or wrong decision. You are trying to walk this journey with the family. It’s impossible for them to have the medical background to make those kinds of decisions. Part of your responsibility is to be as upfront as you can, while also listening. It’s hard sometimes. It’s not your code of ethics you are superimposing.
Brad: And that’s a challenge.
Barb: And you do worry as a physician—you worry about the cost of healthcare, the impact on the family, and mostly, “Do they really understand what the implications are?” The older you get, the less certain you are about prognosticating. The older you get, the more you know what you do not know.
With so much available technologically, do you ever factor in how much care the parents are capable of giving or affording?
Brad: You do what’s right for the kid. It’s not what the parents’ resources are. I think it does impact us though, sometimes. Probably the best example is a kid who has extreme short-bowel syndrome. Their bowel is dead, and you have to take out a large amount of their intestine. That is relatively incompatible with long-term survival. Many times these kids are on nutrition by vein for years, then feeding tubes into their intestine, and end up requiring a small-bowel or liver transplant, which means a lifetime of immunosuppressants. So knowing that path, a premature baby that might have a 14-year-old single mom, I don’t necessarily feel I would be doing what’s best for the kid by going to the nth degree. We would do everything we could to save the child’s life. But how far you go—it’s not about resources, but we do think about social factors.
Maybe a better example would be a highly intelligent, professional family that’s had in-vitro fertilization for years and finally has a kid, and the baby is extremely premature and has a severe catastrophe. The highly intelligent professional is going to be pushing the buttons, wanting everything done no matter what...
Barb: But it still goes back to what the family wants. Now, how things are presented, and how you work with that family… When we were coming through, it was a different model of medical care. The doctors made the decisions and they told the families. Then the pendulum swung: You give this laundry list to families and say, “What do you want me to do?”
It’s got to be exhausting, striking the right balance. Do you ever dream of retiring and playing golf instead?
Brad: I think we are starting to think about it a little bit. That is one of my biggest sources of anxiety right now: What would I do? It’s my life. If I truly get a day off that’s unanticipated, I’m like, “Geez, what am I going to do?”
[Barb apologizes and leaves; she’s helping out another neonatologist by working extra hours.]
How have you and Barb avoided becoming arrogant?
I think our upbringing. The thing that attracted me to Barb is, she’s the most kind, caring person you can know. And I think that makes her a really great doctor, too. I don’t respect people who are arrogant. Sometimes I’m anxious around them. I like working in an environment where people are not afraid to ask questions or say, “Hey, I’m not sure I’d do it that way”—in a nice way. In the end, I think that makes patient care much better. When we are operating, I’ll call my senior residents and say, “Hey, Butt Cheeks, c’mon over.” It just kind of breaks the ice.
One of my mentors was really a tough guy. He trained at Harvard. It was “my way or the highway”—very judgmental, very hard on people around him, very intolerant. It created a high level of anxiety all around him. I think the fear factor probably made me work harder, but it broke a lot of people. I didn’t like seeing that path of annihilation.
