Dr Mohammed Qandil, an Emergency Medicine and Critical Care consultant and member of the Royal College of Emergency Medicine, is head of the Emergency Department at the Nasser Medical Complex in Khan Younis which is in the south of Gaza. At the time of writing and since the beginning of October 2023 there have been over 24 000 reported Palestinian fatalities with over 61 000 injured. Less than one-third of Gaza’s hospitals are functional, millions are at imminent risk of famine and access to humanitarian assistance is minimal.

I have been working in the Emergency Department in Khan Younis continuously since October 2023. Because of the hostilities and the danger surrounding myself and my colleagues, we have not been leaving the site during this time. The hospital has almost become like a closed camp: we sleep in the hospital, we eat in the hospital and essentially we are working 24 hours per day, 7 days per week. The huge escalation in injured patients has meant that we have needed to expand the Emergency Department and critical care capacity. Nevertheless, we are always full.

Most injuries we are seeing come as a result of being crushed under the rubble of collapsed buildings following bombardment and the vast majority of those injured are women and children. Often this happens when the patients are sleeping in their homes and subsequently, we see severe head, torso and limb injuries. To effectively deal with such volume and severity requires continuous operating theatre and critical care capacity. This demand for high acuity care frequently outstrips our ability to provide it and therefore we are endlessly having to make impossible decisions as to which patients should be prioritised because they have the greatest chance of survival.

This situation is compounded by a shortage of medical supplies to the hospital which means there is no luxury of choosing the ‘best’ medication or most appropriate equipment, we are limited by what we have available to us. This, in turn, impacts both the patient’s level of comfort, especially with respect to pain relief, and inevitably their outcome.

While there are many harrowing anecdotes of our work in this period, the situation is ongoing and therefore we remain grateful to our international colleagues for anything they can do to highlight it. What we are seeing as healthcare professionals is indescribable and devastatingly catastrophic. Even at the most basic level we are struggling—some days we are working hungry because we have no access to food. On those days the hospital might be able to spare some vegetables to eat in the evening. Of course, we must remember that this is the situation inside the hospital, where there remains some access to electricity and fuel.

Outside of the hospital, the situation is much worse. There have been outbreaks of gastroenteritis and respiratory infections amongst a population, according to official reports, who are surviving on having food every 2 days, with no access to clean water, no electricity, no fuel and poor sanitation. Even within the hospital there is one bathroom for 500 patients. The humanitarian situation is dire and this compounds an already fragile community who are facing around-the-clock bombardment.

At times we have had no access to a neurosurgeon or a vascular surgeon because colleagues have been too exhausted to work, been injured or been displaced with their families. Some colleagues have been trapped in displacement camps in Rafah, trying to find clean water for their own children, to find food to prevent them from starving and basically trying to keep them safe. The number of healthcare workers is dwindling because they simply have no safe way to get to the hospital.

Words really are not enough to describe what we are witnessing. A short while ago our hospital dialysis unit was hit by a bomb blast, and this was followed by open fire. A few days later the windows of our medical unit were shattered by bullets. Several of the water tanks on the roof of the hospital have been damaged by gunfire and there is an almost constant rumble, like an earthquake nearby. This means that you can be working in the critical care unit and the walls will be shaking around you.

The number of tragic stories is exponential, such as a single survivor from a whole wider family group and innumerable patients who, on a normal day, would attend the hospital and survive to go home but who die because we do not have the capacity to care for them.

A couple of weeks ago, one of our colleagues from the critical care unit was walking on the street to buy some milk for his children and he was caught in an airstrike. He attended our Emergency Department with a traumatic pneumothorax and multiple limb fractures. We were able to save his life, but he is now unable to walk. We sadly lost a dental colleague who was killed, again, simply walking in the street.

We look very much to the international community and humanitarian organisations to bear witness to this immense human suffering. We especially welcome the support of emergency medicine societies across the world who will understand the magnitude of what we are facing. Outwith the utter devastation, if we can survive this war, the skills and knowledge we have gained will prove useful to our colleagues. We are seeing devastating injuries, many of which we may have read about in textbooks and expected to see once or twice in a career and yet we are facing them dozens of times over. These include the so-called high acuity, low occurrence (HALO) procedures like emergency caesarean section and clamshell thoracotomy. In our day-to-day practice HALO now seems like a misnomer.

We have extensive experience of performing intubations and chest drains with the patient on the ground when there is often no bed. We are learning that the text-book approach may not be the most effective when faced with the reality of needing to perform many procedures. Even our experience of Glasgow Coma Score as an outcome predictor in the paediatric group has been repeatedly challenged. We have found many cases where a child has decerebrate or decorticate posturing and a normal CT head scan, who might seem to be in an unsurvivable state, but if ventilated and oxygenated they can make a full recovery. These cases are likely to have been pulled from beneath the rubble and subject to dust inhalation/suffocation leading to hypoxia and therefore abnormal posturing, rather than being primarily victims of a head injury.

As healthcare workers we have nothing to do with the conflict, but we are stuck in the centre of it and need support and help to guarantee our safety. We need this to carry on caring for the constant stream of patients because we take it on as a humanitarian duty. We are so grateful for the support of international colleagues: it helps us feel supported and less alone and we really do miss them when they leave. Certainly, without a ceasefire, humanitarian support, medical support and medical supplies this dreadful situation cannot improve.

Not applicable.

MQ thanks Dr Anisa Jafar from the Humanitarian and Conflict Response Institute at the University of Manchester/Royal Manchester Children’s Hospital for providing support in editing language and syntax. He also thanks Dr Chris Hook from Médecins Sans Frontières/Bristol Royal Infirmary, UK, for working alongside him and his colleagues and then making it possible for him to share his story.