Easter morning, 2008.
Dawn Dubsky opened her eyes, her consciousness rising through a soup of painkillers and sedatives. She had been waking sporadically, and every time she did, those watching over her hospital bed shared the same bleak thought:
This could be the day she figured out what happened.
It had been one month since Dubsky, then 32, a pediatric nurse fresh from a trip to Africa, entered a Chicago emergency room with a crushing headache and a 103-degree fever -- signs, she correctly guessed, that she had contracted malaria, a disease that claims nearly 1 million lives each year in the developing world.
That human wreckage goes largely unnoticed here. An army of public health workers eliminated the mosquito-borne illness in the United States more than 50 years ago, and on the rare occasion a traveler brings it home today, it is usually no match for Western medicine.
Dubsky's case was different. Despite the efforts of 15 doctors, the microscopic parasite that causes malaria rampaged through her bloodstream, blowing up cells, clogging veins and arteries and shutting down vital organs. Her skin blistered and turned purple. She started to die an inch at a time.
A barrage of drugs finally subdued the parasite, and Dubsky pulled through. But survival had come at a price -- one she was just starting to recognize.
Dubsky peered at the bandages covering her body. Her face clouded with confusion. She looked again. At last, she spoke.
"Mom," she said, "where are my arms?"
"Oh, Dawn," her mother replied. "Your arms and legs are gone."
Malaria had destroyed so much of Dubsky's tissue that a surgeon had to amputate her limbs just below the elbows and knees. The procedure saved her life but left her utterly transformed.
Dubsky had been a woman of fierce independence, an adventurer who ran marathons, skied the Rockies and traveled the world on little more than a whim. Now she was helpless, unable to even sit up by herself.
It was too much to fathom -- too much to bear. And so, in a furious voice, Dubsky asked a question:
"Why didn't you let me die?"
Her mother begged her to never say that again, but the thought endured, following Dubsky along a path of pain. Only gradually would a new purpose reveal itself, one that joined her suffering to a titanic global struggle.
Why wasn't she dead?
The answer was simple. Her life's work had yet to begin.
Nothing to fear
No one was surprised when Dawn Dubsky decided to become a nurse after graduating from Andrew High School in Tinley Park. She was a born caregiver, covering up for her older siblings' teenage indiscretions and comforting her mother through the strain of divorce.
Yet her interest in the profession was only partly benevolent. What really appealed to her was its promise of freedom.
So after earning her degree from the University of Iowa in 1998, she was gone, finding work in California, Mexico, Colorado and Hawaii and spending her off time in exotic pursuits. She dove with sea lions in the Sea of Cortez, surfed the big waves of the Pacific and shot down black diamond slopes strapped to a snowboard.
"She didn't think about things -- she just did them," said her best friend, Olivia Bradley. "Later on she might say, 'I was really scared,' but I could never tell."
Dubsky eventually drifted back to Chicago, eager to spend more time with her nieces and advance her career. She had discovered an enthusiasm for children during stints as a summer camp nurse, and in 2004 she took a job in the organ transplant unit of Children's Memorial Hospital.
But as Dubsky reached her 30s, she felt the old itch for change. She had long had an interest in fashion, and with an eye toward a possible career switch, she took classes at the International Academy of Design and Technology in the Loop.
It was there one day in late 2007 that she saw a flier advertising a two-week retreat to study textiles and jewelry in the west African nation of Ghana. The pairing of two passions, design and travel, was irresistible. She quickly signed up.
Most of her family and friends thought nothing of it. Only her mother, Deborah Chandler, was nervous.
She was a junior high school teacher and had taught African history as part of a social studies class. Despite Ghana's reputation as a relatively safe and stable country, her daughter's trip stirred a host of frightening thoughts. What about political strife? What about sanitation? What about disease?
Dubsky told her mother everything would be fine. And on Feb. 4, 2008, she left O'Hare International Airport as planned, with one suitcase lightly packed with clothes, the other crammed with medical supplies she had volunteered to ferry to a Ghanaian health clinic.
"Not to worry," Dubsky wrote in an e-mail to her mother the next day. "I'm safe. I'm here. It's beautiful."
So it was -- hot and crowded yet vibrant. There was so much to see and do, but for Dubsky, the first order of business every morning was to mist herself with bug spray. It was an imperfect defense against the threat of disease-carrying mosquitoes, but she figured it would be enough.
Dubsky had declined to take medication designed to shield her from malaria. Though she knew the disease could be a killer, she wasn't particularly concerned: A Ghanaian acquaintance had said mosquitoes would be rare that time of year, and Dubsky judged the medication's possible side effects, from intestinal distress to hallucinations, to be the greater hazard.
Besides, she was laid-back by nature. She wasn't even alarmed when, lounging by a resort swimming pool, she felt a slight irritation on the back of her right leg and realized she had been bitten.
She was an American, young, healthy and strong. She had access to the world's most advanced medical care.
There was nothing to fear.
Under her skin
The invasion begins the moment an infected mosquito starts to feed. The insect's saliva carries a few dozen or so malaria parasites, which resemble microscopic earthworms, into the body of their new host. Within an hour, the circulatory system propels them to the liver.
There, they penetrate the cells of the organ and multiply. It is painless. For about a week, the host doesn't feel a thing.
Then the swollen liver cells rupture, dumping swarms of hungry parasites into the bloodstream. They enter red blood cells, growing fat on oxygen-carrying hemoglobin before replicating again.
The cells bulge and explode, sending forth new waves of attackers, and the cycle repeats. By the time the host notices that he is unusually fatigued, the incursion has become a takeover. Hundreds of millions of malaria parasites can be swimming in his veins and arteries.
Sometimes malaria even turns the host's body into the enemy. The immune system counterattacks with such ferocity that it becomes an even greater destructive force than the parasite.
Experts say someone with a severe case in the developing world probably would die before the disease displayed the full range of its power. That's the thing about Americans who contract malaria. Technology can keep them alive long enough to find out just how bad it can get.
Too sick to be afraid
Dubsky felt drained as the retreat neared its end. When her plane took off for home, she dozed for nearly the entire 22-hour journey.
The weariness lingered after her return on a Tuesday, but she wrote it off as jet lag. It wasn't until that Friday, 13 days after she had been bitten, that she knew something was wrong.
She dragged herself to her shift at Children's Memorial but grew steadily weaker throughout the day. Her stomach soured. Her head felt as though it was being squeezed into pulp.
She left early and got a few hours of sleep at home. When she woke, drenched in sweat, she took her temperature. It was 103 degrees.
Early the next morning, she took a cab from her Lakeview apartment to Northwestern Memorial Hospital and told the emergency room doctor what she thought was happening. A blood test confirmed it, and Dubsky left the diagnosis on a friend's voice mail:
"I got da malaria!" she said in an exaggerated Chicago bray.
Though her family and friends raced to the hospital, Dubsky wasn't terribly worried. The infectious disease specialist who examined her on Saturday afternoon judged the case to be "uncomplicated," with no sign of shock or other serious symptoms. Only 2 percent of Dubsky's blood cells were infected (it can go up to 50 percent).
The doctor prescribed a standard treatment: a week's worth of quinine sulfate tablets. But quinine isn't easy on the stomach, and Dubsky repeatedly threw it up. She insisted on getting her medication through an IV, but hospital staffers said taking it by mouth would work faster.
After a wretched night of shivers and chills, Dubsky grew far worse. Her fingers and toes tingled. Her blood pressure plunged. Jaundice turned her skin as yellow as old newsprint.
Worse, a test suggested the onset of DIC, or disseminated intravascular coagulation, in which the body's blood-clotting system spins out of control. It is a major complication: Doctors sometimes joke grimly that DIC stands for "Death Is Coming."
Late that afternoon, Dubsky's hands felt like clubs, her lower legs as though they were encased in ski boots. She hobbled to the bathroom but was unable to urinate, a sign that her kidneys were starting to fail.
On her way back to bed, Dubsky peeked in the bathroom mirror.
"Mom, look at me," she called out.
Her mother glanced up. Dubsky's lips had turned blue.
A few moments later, Dubsky's breathing grew labored as tiny blood vessels, dilated by her body's wild response to the infection, leaked fluid into her lungs. It was a harbinger of septic shock, a potentially fatal condition.
Hospital staffers raced Dubsky to the intensive care unit, where she signed papers directing the physicians to do all they could to save her life.
Her brother, Tom, a pipe fitter and former junior hockey player, wept as he begged Dubsky to fight. Her mother, kneeling at the foot of Dubsky's bed, sobbed that she was terrified.
"Mom," Dubsky replied, "I'm too sick to be afraid."
It was the last thing she would say for weeks.
Losing her grip
A few hours later, Dr. Richard Wunderink, director of Northwestern Memorial's intensive care unit, met his sedated patient. He had cared for a few people stricken by malaria over the years, but none had been so sick.
A ventilator was doing the breathing for her. She was about to be hooked to a dialysis machine that would stand in for her failed kidneys. And even though she was on three medications to increase her blood pressure, it was still perilously low.
Then there was her skin. A patchwork of purple blotches was breaking out on her belly, nose and especially her lower legs and arms. Her darkened fingers had curled into cold, stiff claws.
Some of that was due to the medication combating her low blood pressure. The drugs caused the vessels leading out of her torso to constrict, keeping the blood concentrated near her vital organs and brain. But that meant little was reaching her extremities.
It was a regrettable but unavoidable consequence of the treatment for septic shock, Wunderink said later. If Dubsky's heart, lungs, liver, kidneys and brain didn't receive sufficient blood flow, she was going to die.
After a few tense days, her vital signs improved. Her skin did not.
The coldness crept upward from her hands and feet, even after she'd been taken off blood pressure medicine. Large blisters boiled up and burst on her arms and legs, evidence that malaria-deformed cells had blocked the blood flow to her skin.
Wunderink, concerned that her brain had suffered similar blockages, ordered a CT scan. To his surprise, the image was flawless. Regardless of how thoroughly malaria had ravaged Dubsky's body, her brain was intact.
With that, the doctor knew it was time to send Dubsky along. The parasite had been suppressed to a nearly undetectable level, and Dubsky was stable enough to be transferred to a burn unit, where a specialist could treat her devastated skin.
Wunderink was confident Dubsky would live, but he was equally sure that she was going to lose part of her body. He had known it the moment he saw her. The only question was where it would end.
Her living nightmare
The ambulance pulled away from Northwestern Memorial and headed south, bound for the University of Chicago Medical Center. A convoy of Dubsky's family and friends followed.
Despite Wunderink's optimism, Dubsky was still in critical condition. Forty percent of her skin was blistered. Her limbs were dotted with ink marks where the doctors had tried to find a pulse.
Yet inside the ambulance, Dubsky slumbered. Time had stopped, but her dreams went on.
She was underwater, a scuba diver, and though she was running out of air, she couldn't break the surface. She felt a surge of danger, as if she were fleeing something menacing but couldn't get away.
Then she was trapped in a casket. Two men with a chain saw argued over whether to cut the box in half. She wanted to scream, but no one could hear her, no one could help her, as the saw roared to life.Copyright © 2014, The Baltimore Sun