Early on Tuesday morning, within minutes of the wave of Israeli airstrikes that broke the fragile two-month ceasefire which had brought some respite to Gaza, the emergency room of al-Aqsa Martyrs hospital in the central town of Deir al-Balah was full.
“At no point were there less than 65 people in ER, all with open wounds, mainly women and children … The floor was awash with blood,” said Mark Perlmutter, a US-based volunteer orthopaedic surgeon working at the hospital that morning.
Just a few kilometres away, there were similar scenes at Nasser hospital in the southern city of Khan Younis.
“There was just wave after wave,” said Tanya Haj-Hassan, a paediatric intensive care doctor. “As soon as patients had died or been sent elsewhere and we cleared some space, more would come in. It was chaos. One doctor stepped on a corpse on the ground as he tried to do a life-saving procedure on a child.”
Palestinian medical officials say more than 200 people were killed on Tuesday morning alone across Gaza, and hundreds more injured. Within five days, as more airstrikes and shelling continued, the overall death toll in the devastated Palestinian territory in the 18-month war would reach 50,000, comprising mostly women and children. A total of 113,274 others had been injured, the health ministry said.
Israeli military officials say 80 “terrorist” targets in 10 minutes were attacked on Tuesday morning, including leaders and key military infrastructure.
The Israel Defense Forces (IDF) has previously blamed high levels of civilian casualties on Hamas, the militant Islamist organisation that launched the attack into Israel in October 2023 that killed 1,200, mostly civilians, and triggered the war. Israel accuses Hamas of using civilians as human shields, a charge it denies.
At Nasser hospital, more than half of adult casualties brought in on Tuesday night were given a 20-second check by surgeons – then, in an effort to prioritise those whose lives might be saved, whoever had brought them was told there was nothing that could be done. Children were almost all admitted, even when their injuries were clearly fatal.
“They had been sleeping so were coming in wearing pyjamas, wrapped in blankets. Often it was neighbours bringing them because the parents had been killed. It was horrific. We had to stop resuscitating several kids simply to focus on one who had a chance,” said Haj-Hassan.
Feroze Sidhwa , a 43-year-old trauma surgeon from California, in Khan Younis as a volunteer with the medical charity MedGlobal, described telling the father of one four-year-old girl that his daughter was not going to live more than a few more minutes. “I had a look … She had very serious head injuries … I told her dad to take her outside and be with her and pray with her and he did,” Sidhwa told the Guardian.
Many of the 300 brought into Nasser hospital on Tuesday did not survive. Ahmed al-Farra, head of the paediatric and obstetrics department, said about 85 people died, including about 40 children aged one to 17.
The average age of the children pronounced dead at Nasser hospital after this week’s new wave of attacks was between six and eight years old and about 35% of all casualties were under 14, said Morgan McMonagle, an Irish vascular surgeon volunteering with the NGO Medical Aid for Palestine.
Among the casualties was a 10-year-old boy with a severed spinal chord who was completely paralysed from the neck down and who was unable to breath unassisted, and a five-year-old with multiple shrapnel injuries including to her brain who was unlikely to speak again.
In a statement, the IDF said it was committed to mitigating civilian harm during operational activity and made great efforts to estimate and consider potential “civilian collateral damage” in its strikes.
“The IDF is fully committed to respecting all applicable international legal obligations, including the law of armed conflict. Considerations and obligations with respect to proportionality and military advantage are evaluated and applied on a case-by-case basis and are facilitated by the comprehensive integration of the law of armed conflict into every phase of training, planning, and execution of military operations,” the statement said.
Israeli political leaders have warned that attacks will intensify until Hamas frees more hostages and gives up control of Gaza. Hamas took 251 hostages in its October 2023 raid into Israel and continues to hold 59. Returning hostages have reported systematic abuse and poor conditions in captivity.
The first six-week phase of the ceasefire agreed in January expired in early March. Israel proposed an extension of 30 to 60 days and further hostage-for-prisoner exchanges instead of an agreed second phase that would have led to a permanent end to hostilities.
Only 22 of 35 major health facilities in Gaza are still functioning, each only providing a fraction of the services offered before the war. Thirteen are currently receiving casualties from the ongoing airstrikes.
Olga Cherevko, a spokesperson in Gaza for the UN’s office for the coordination of humanitarian affairs, said that all were “overwhelmed” and suffering shortages of essential supplies even though stocks were brought into the territory during the eight-week ceasefire.
“It’s hard to measure the exact level of supplies … [but] we have never had such a long closure. Literally zero has come in,” she said.
Doctors at al-Aqsa Martyrs hospital said stocks were running low. “It was very difficult emotionally, even after 18 months of conflict. We only have ten beds, and we are short of so much: gauze for burns, gloves, cleansing materials, dressings,” one surgeon, who requested anonymity, said.
Dr Khamis Elessi, a neurologist and pain specialist at al-Ahli hospital in Gaza City, said he had no painkillers of sufficient strength for hundreds of cancer patients. “We have hundreds of thousands in Gaza with chronic diseases. They need the right care but conditions are terrible. There is no safe water, sanitation systems are all destroyed so infections are spreading everywhere and people are terrified,” Elessi said.
Israel continued to allow medical evacuations from Gaza but only a few dozen left daily and more than 14,000 needed urgent treatment outside Gaza, Cherevko said.
Most facilities in Gaza now also have well-practised routines for mass casualty incidents, though even these proved inadequate last week. “We have plans, good plans, but the problem is that the number [of casualties] is greater even than our plans,” said Dr Fahd Haddad, medical director of a field hospital near the southern town of Nuseirat.
Haddad said his facility too was short of supplies. “We are afraid we will run out. If there is a long term closure then we cannot survive,” he told the Guardian.
But the biggest challenge the 38-year-old and his colleagues face is maintaining their own morale after hopes of a permanent ceasefire were shattered. “We woke up that Tuesday to the explosions and it was like a flashback to 18 months ago when the war began,” Haddad said. “We were so happy with the ceasefire. Life was very tough but at least there was no killing.”
