Exhausted emergency room doctors working in two Egyptian hospitals estimate that at least 45 people have died from injuries suffered in the street battles by protesters demanding that President Hosni Mubarak step down, and in Cairo alone treated more than 900 people who were shot, stabbed or struck in the head by rocks.
The Egyptian government has yet to provide official casualty figures for the unrest, citing only eight dead and nearly 900 injured in violence that rocked Cairo Wednesday into Thursday, and an estimated 5,000 injured since the unrest began. The overall number of fatalities likely exceeds 45 because other hospitals could not be reached or did not offer figures. Navi Pillay, the top United Nations human rights official, estimated on Tuesday that, based upon unofficial reports, 300 people had died by that day.
Most of the wounded brought to Cairo University were treated for mild to moderate injuries and released. But on Thursday, 86 severely wounded patients remained at the hospital. The worst-injured suffered brain trauma from bullets, depression fractures from large stones and "massive lacerations of the liver" caused by knives and other sharp tools wielded in street attacks around Tahrir Square, said Dr. Alia Abdel Fattah, a critical care specialist overseeing emergency and intensive care units at the university's nine hospitals.
Fattah estimated that in two days, her staff saw 62 ruptured globes, which are tears in the surface of the eyeball, created during trauma.
Fattah said some of the most critically ill "died just on arrival, and some when we were doing resuscitation, because they arrived late." She counted 10 deaths at the hospitals in the first four days of protests, and another five to six deaths on Wednesday.
In Alexandria, a physician who asked not to be publicly identified, said that last Friday, he saw "masses of people coming into our ER" and estimated that "about 30 protesters" had died on arrival after being hit by "gunfire from live bullets to the chest, abdomen and head." He described "tens of patients" with bullet injuries to the chest, and others with bullets that had penetrated their brains and left them "deeply comatose." Like many doctors and surgeons, he described large numbers of people treated for "ruptured eye globes due to rubber bullets."
Despite the early chaos, he described relative calm in Alexandria on Wednesday, when his hospital had no trauma cases.
Reports from hospital-based physicians suggested that casualties and deaths far outpaced official figures provided by the Egyptian government. On Thursday, Egypt's health minister told state television there were five dead and more than 800 injured after overnight violence.
As emergency and critical care services were continuing apace, patients in many cities were facing significant obstacles to surgery, scheduled appointments, diagnostic tests and services such as kidney dialysis. Although major public hospitals were faring well, curfews impeded many health professionals' ability to get to other hospitals, clinics and medical offices, and their patients' abilities to see them. Public transportation was shut down and many gas stations were out of gas, further thwarting the mobility of patients and doctors. Several doctors conveyed their own and their patients' increasing wariness about encountering armed thugs in the sometimes lawless streets.
"Medical care has been disrupted to a big extent," said Dr. Adel Allam, an internationally renowned cardiologist whose private practice is closed, but who continued seeing patients at Al Azhar University in Cairo. "Because of the curfew and the situation, the private places, like private radiology centers, they are not getting the usual flow of patients, and most of them are closed."
With Egypt's banks closed, many patients couldn't come up with the out-of-pocket cash payments typically made for medical appointments. Egyptians can get only emergency services when they cannot pay.
To accommodate the influx of newly injured and wounded patients, Cairo University Hospitals reorganized the delivery of medical services, which included closing an outpatient service and converting it to an emergency service, Fattah said.
"We evacuated most of the stable patients from the main hospital when we started to receive many wounded patients after Jan. 25th," Fattah said. Doctors doubled emergency room capacity by preparing 200 beds, and doubled the number of senior staff on call to make sure they had experienced doctors available 24 hours a day. "You can see a lot of professors in surgery," Fattah said.
Emergency and critical care services fared better than other types of medical services in the capital city. For example, operating rooms at the National Cancer Institute hospital closed for a week, partly because nurses, doctors and technicians had difficulty commuting through the chaos. Curfews made it even harder to get to and from work, said Dr. Mohamed Shaalan, a professor of surgical oncology at the National Cancer Institute at Cairo University Hospital.
"Today was the first day I operated on a cancer patient after a week of not being able to operate," he said in a telephone interview Thursday. However, in a sign of how flexible some health professionals have been in recent days, Shaalan said that as a favor to friends, he went to a small private hospital to surgically remove a bullet from the scalp of their 23-year-old son, a young demonstrator who had been struck in the head while fleeing security forces in Cairo.
Shaalan, a breast cancer specialist, said he had to close the offices of the Breast Cancer Foundation, which he chairs, because of proximity to Tahrir Square. As a result, many women couldn't get the mammograms or breast prostheses the foundation provides free. Most diagnostic centers and pathology labs were closed, forcing his cancer patients to wait for important imaging tests. A patient with cancer of the head and neck was supposed to have a PET scan earlier this week, but the test was postponed until Sunday because the facility didn't have required materials.
"Right now, I have a 40-year-old woman who needs another biopsy and an MRI," Shaalan said. "Another patient called me today and said, 'I'm in front of the pathology lab and it's closed. What can I do, Can I go to another lab?' It's difficult to do all that when there's all these fights downtown. It's not very safe; it's not easy."
He said that most of the medicine in Egypt is provided in private clinics that operate in the late afternoons and evenings. However, because of curfews, most of the private clinics were closed. "I get all the time calls from the patients [asking] 'when are you going to your clinic? When can we see you?'" Shaalan said. "I say 'don't come to the clinic, I'll meet you at the hospital to change dressings.' Women I operated upon last week need someone to pull out the drains. They need to see somebody."
The risk of encountering street violence was enough for Shaalan's mother-in-law, a kidney failure patient, to travel to a seaside resort for every-other-day dialysis, he said. "She goes for renal dialysis 100 meters away from the Tahrir Square in the Cairo Kidney Center. She went to another city on the Red Sea 500 kilometers away to have dialysis to not have to go through these crowds."
Shaalan also sent his wife and young sons, ages 6 and 8, to the Red Sea on Tuesday. "The kids were scared in seeing … hearing all these shots. They watch on TV what's happening. The criminals were out of the prison. It wasn't even safe in one's own house," he said. "They feel better now."
All nuclear medicine scans were cancelled because the necessary radioactive isotopes were stuck at the airport, said Allam. The isotopes normally are transported, with an accompanying police car, to Egypt's atomic agency, "where they look at them, clear them and take them to the hospital. This process cannot be done because there are no police."
However, there hasn't yet been any indication that heart attack patients are staying away from hospitals, he said. Five Cairo hospitals and a sixth in Alexandria that are collaborating on a cardiac study were reporting no decline in heart attacks being treated this week.
But he said, given medical findings that "during times of mental stress, the number of myocardial infarctions do increase," the cardiologists will have to wait for updated reports to see if there was any difference between heart attack incidence "at the time of this big crisis" and calmer times. Allam said it was possible that the curfew might be making it difficult for patients in distress to come to the hospital, because most Egyptian cardiac patients arrive by car, with only 5 percent transported through the emergency system.
As traditional ways of delivering and getting access to care became more problematic, creative doctors found new ways to serve patients in need.
"Most of my patients call me for medical advice because with the curfew it is not possible to see them in person and they feel more comfortable (the parents) to do this in the mornings so that if they need any medications they can find it easily," said Dr. Yasmin Galal, a pediatrician who practices in several different Cairo areas. With the resumption of Internet service two days ago, Galal and friends in several medical specialties created a Facebook page with their specialties and phone numbers "so that if anyone during curfew is in need they can call us."
Volunteer doctors set up makeshift clinics in mosques to deliver some primary care services, including one in Tahrir Square that Allam saw while watching television. He said these clinics have been started by the Islamic brotherhood to garner popular support. "They are very organized," he said. Not all men and women whose more complicated cases, such as gunshots, were willing to be taken to university hospitals for care, according to Galal. Some "were refusing to get into the ambulance for fear of being not taken to a hospital and being captured/arrested by police."
Galal said primary care units were "lacking basic supplies at the moment and were calling for help, like alcohol, Betadine, needles for stitches, and gauze. People are trying to deliver the needed medical supplies, but are being prevented and terrorized by thugs with no one protecting them, not the police not the military." She said there is also a need for blood donations.