Editor's note: This story contains graphic descriptions of injuries.
AMMAN, Jordan — At one of the last functioning hospitals in Rafah, scenes of horror are conveyed in clinical descriptions as U.S. medical volunteers grapple with the effects of Israeli military operations and border closures after seven months of war in Gaza.
"They tried to suture up the hole in the heart — they couldn't," Dr. Usman Shah, from California, explains to Dr. Ammar Ghanem about a patient wounded in an explosion. Ghanem, a vice president of the Syrian American Medical Society, is overseeing the intensive care unit and made a video on Friday of his conversation with Shah.
"There was too much blood loss – the heart cavity, they tried to massage it but the heart cavity was empty," Shah says.
The two are members of a team of U.S. and U.S.-trained doctors who arrived in Rafah 10 days ago as part of a medical mission organized by the Palestinian American Medical Association. Now, nearing the end of the mission, with Israel closing the main border crossing, they are unable to leave.
In the video recorded Friday by Ghanem, Shah tells him about the other two patients who arrived that morning with non-survivable injuries.
Shah, dressed in blue scrubs, relates in an even voice how the jaw of one of the patients crumbled under his hand when he touched him. In the only visible sign of distress, he massages his temple and briefly closes his eyes as he tells the story.
Ghanem says conditions have worsened considerably since the border closure on May 7, with many of the local physicians and nurses unable to come to work because they have had to evacuate their families.
'Prioritizing patient lives'
Most of the doctors and nurses on the mission are experienced conflict zone volunteers. But Ghanem says they have never seen anything like this.
"Unfortunately here I have to prioritize patient lives. When I say 'prioritizing patient lives' I mean I know that term but I never used it before until I came here," he said in an interview with NPR by video call from Rafah.
The benign-sounding term refers to deciding whom to stop treating and let die in order to divert resources to those with a better chance of surviving.
In one of two videos sent to NPR from the hospital Ghanem points out to a colleague one of his most difficult cases – an 18-year-old woman with a skull fracture so severe that brain material was visible. He said they did not have drugs strong enough to keep her sedated.
He said they stopped treatment for a woman suffering from acute pancreatitis after two days because she required continued oxygen that might support several other patients.
"So you see how sad this is?" he said in the interview. "I mean this patient is only like about 60 years old. We will not do this in the U.S. as you know, but this time of war and lack of resources that we are forced to do this."
Ghanem, who did not want the hospital identified for security reasons, estimated that two to three patients a day die in the intensive care unit because of lack of supplies or equipment.
A lack of essential supplies
Part of the problem is that items critical for hospitals are banned by Israel which says they can be used by Hamas for military purposes. The list of items it considers dual-use include some water disinfection materials.
The list does not cover all items that are reportedly banned. Save the Children has said it has had shipments rejected by Israel because they contained sleeping bags with zippers. An Israeli legal center, Geisha, has compiled a list of items that have been reported by organizations to have been rejected, including fishing rods and plastic sheets for tents.
The result, according to the U.N. and international aid agencies, is long delays and a spiraling crisis in humanitarian aid.
After the killing of seven workers in Gaza from the U.S.-based World Central Kitchen last month, Israel, under U.S. pressure, pledged to allow in more aid, improve coordination and to safeguard humanitarian staff.
A statement issued this week by seven major international aid organizations, including Save the Children and Care, said those pledges have not been fulfilled.
"Humanitarian actors see no significant improvement from Israeli authorities in addressing the dire challenges to prevent life-saving aid for Gaza's 2.3 million residents," the statement read.
Israel denies that it holds up aid.
International aid and medical workers who were either in Rafah or who had recently left, warned at a press briefing this week that the damage to Gaza infrastructure, lack of clean water, ongoing attacks and increasing starvation had brought humanitarian operations to the brink of collapse.
Israel has issued evacuation orders to sectors of Rafah, where more than 1.3 million people are crammed in near the Egyptian border. But for many there is no where to go.
Ghada al-Haddad, a Gaza-based communications officer for Oxfam, said families were pitching makeshift tents on sidewalks and in graveyards. She said others had moved to the beach, where there is no clean water and no sanitation.
Oxford professor Dr. Nick Maynard, a surgeon from England who traveled to Gaza three times on medical missions since the start of the war, said most of his time over Christmas was spent operating on major explosive injuries to the chest and abdomen. He said on his last trip this month that complications due to malnutrition in trauma cases had increased.
"I operated on many patients in the last two weeks who had awful complications from their abdominal surgery related to inadequate nutrition and particularly those with the abdominal wall breaking down," he said. "Literally their intestines end up hanging outside."
He said the hospitals lacked even colostomy bags along with materials to manage wounds and provide nutritional support.
Maynard said two of his patients, girls age 16 and 18, had survivable injuries but died last week as a direct result of malnutrition contributing to their deaths.
"We will see more of that in the coming months," he predicted
"We're at a tipping point right now," said Dr. John Kahler, co-founder of MedGlobal, a U.S.-based medical aid organization. He said Palestinian children before the war were getting only about 80% of the calories they needed. Now, seven months into the war, the effects of consistent deprivation are showing.
"It's at that time that the immunological system begins to break down," he said. "It's at that time where infections and complications of malnutrition will start."
Desperate for fuel
Aid officials said particularly alarming is the lack of fuel being allowed in. Most of Gaza's infrastructure has been destroyed and Israel has so far allowed fuel trucks to enter only through the main Rafah border crossing. That. crossing has now been closed since the beginning of the week.
"The whole aid operation runs on fuel," said Jeremy Konyndyk, president of Refugees International. "That means water can't be pumped, lights can't be kept on in hospitals, vehicles cannot distribute aid. So if the fuel is cut off the aid operation collapses, and it collapses quickly."
The Israeli military on Friday in an apparent response to the concerns said it had transferred more than 52,000 gallons of fuel to be made available to international organizations in Gaza through Kerem Shalom crossing into southern Gaza.
The head of the U.N.'s relief operations, Andrea De Domenico, told the French press agency AFP that amount of fuel was needed each day to maintain operations.
White House national security spokesman John Kirby on Friday said the U.S. wants the Rafah crossing, the only one able to handle large numbers of fuel trucks, opened immediately.
"Every day that that crossing is not available and usable for humanitarian assistance, there's going to be more suffering, and that's of deep concern to us," he told reporters. "And so once again, we urge the Israelis to open up that crossing to humanitarian assistance immediately, that aid is desperately needed."
At the Rafah hospital on Thursday, Monica Johnston, a burn nurse from Portland, Ore., was back at the ICU, only partially recovered from a gastrointestinal infection that left her dehydrated, dizzy and nauseous.
One of her patients was a 7-year-old boy with burns over 80% of his body.
"We're running out of pain medicine, running out of blood pressure medicine. So we cannot keep these people alive or comfortable. It's absolutely horrifying what we're seeing here," she said.
Johnston said everyone was desperately hoping for a cease-fire. (Israel says it is rejecting a sustained ceasefire because it needs to eliminate Hamas's military capability.)
"[A ceasefire]s will enable us to finish our mission, enable new help to come in, new supplies to come in, and eventually enable our safe return home," she said.
