In the heart of Gaza City, as its citizens again find themselves under fire from Israeli airstrikes and artillery, the wounded and their wailing families stream into Shifa Hospital without end.
Shifa, Gaza's largest hospital, only has an 11-bed emergency room and six operating theaters. Yet amid power cuts and among the screams of the bereaved, doctors at the 600-bed facility have become masters of improvisation, forced by the seemingly unending conflict engulfing the coastal strip to care for the wounded.
"If we are in the middle of an operation (and) lights go out, what do the Palestinians do?" said Mads Gilbert, a Norwegian doctor who has volunteered at Shifa on and off for 17 years. "They pick up their phones, and they use the light from the screen to illuminate the operation field."
The wounded from Israeli strikes usually arrive in waves. More than 3,000 Palestinians already have been wounded in the past two weeks of fighting, health officials say. Many, including the most serious cases, end up at Shifa.
A new wave of casualties arrives after daybreak Sunday, following a night of heavy Israeli tank fire on Gaza City's Shijaiyah neighborhood. Hospital guards shout at drivers to move to make room for the next vehicles, pushing back journalists and onlookers.
Some of the wounded get treated in a hallway near the emergency room. A medic bandages the foot of an emergency worker writhing in pain on a mattress on the floor. A little boy with shrapnel wounds arrives and the emergency worker slides off the mattress to the hard floor for the child.
Nearby, a woman cries hysterically. A man holds up a dead child, wailing. Another carries a teenage girl whose right arm is bloodied and broken.
Patients on gurneys line up outside the X-ray room. Relatives of the wounded, one in a blood-soaked white undershirt, argue over who will be examined first.
Dr Jihad Juwaidi says his six operating rooms filled up quickly and that even the seriously wounded have to wait for surgery, including a little girl with a fractured skull.
Choosing who gets treated first is gut-wrenching, says Dr. Allam Nayef, who works in one of Shifa's intensive care units.
"Sometimes you have to select which one of them has the best chance to survive," Nayef says. "Easily in this rush, you can take a bad decision, that the one (patient) you thought will wait for you ... you won't find him when you finish your surgery."
By 2:00am Saturday, only two of the four beds in his ICU are occupied.
One patient is a 4-year-old boy hit by a car when Gaza residents rushed into the streets to restock during a humanitarian cease-fire last week. The other, a 22-year-old, suffered serious head injuries in an Israeli strike — a direct hit on a house that killed 18 members of his extended family. The target, Gaza's police chief, survived.
At about 3:00am, a new patient with a serious brain injury from shrapnel is wheeled in. Neurosurgeons had patched him up downstairs, but his prognosis is bad. All that's left for Nayef is to try to stabilize him.
Nayef and his colleagues work 24-hour shifts. A storage area crammed with boxes and an old vinyl-covered sofa doubles as a lounge where the doctors rest until the next wave.
Even in peak hours, there is some order in Shifa's seeming chaos.
This is the third round of major hostilities between Israel and the Islamic militant Hamas in just over five years. Everyone at Shifa — doctors, nurses and bearded Hamas policemen in blue camouflage uniforms — knows their part during a crisis.
Like in the last bout of fighting in 2012, TV crews have set up camp in the yard outside the main entrance. Shifa is seen as relatively safe, an unlikely target of Israeli airstrikes, but some correspondents still wear body armor for on-camera reports.
Hamas political leaders show up in the courtyard occasionally to speak to reporters. They usually keep a low profile, but use the massive media presence in a safe location to get their message out.
Working at Shifa requires ingenuity.
The power goes off repeatedly as aging hospital generators buckle under daily rolling blackouts Gaza residents have lived with for years. Many items are in short supply, from gauze to adrenaline. They also lack spare parts for worn equipment, with bedside trolleys clattering down hallways on rusted wheels.
Only three of Nayef's four ICU beds have ventilators. One broke down long ago and can't be repaired. He says he once made a special wire for cardiac pacing from a spliced Ethernet cable.
Shifa's problems began well before this round of fighting. They are rooted in the decades-old Israeli-Palestinian conflict and more recently in the rivalry between Hamas and Western-backed Palestinian President Mahmoud Abbas.
Israel captured Gaza in 1967, along with the West Bank and East Jerusalem. Abbas' goal of a Palestinian state in all these areas remains elusive after two decades of failed negotiations. Hamas envisions an Islamic state in all of historic Palestine, including what is now Israel, and has carried out bombing, shooting and rocket attacks against Israel since the group's founding in 1987.
Israel withdrew from Gaza in 2005, leaving it to Abbas' Palestinian Authority, and Hamas seized the strip from Abbas by force two years later. In response to the Hamas takeover, Israel and Egypt have blockaded Gaza, restricting trade and movement. The blockade has set Gaza back years, and now the growing financial problems of Hamas and Abbas' Palestinian Authority, based in the West Bank, have compounded the shortages.
Israel says it allows in medical supplies except for "dual-use" items — anything it suspects could be diverted by Hamas for military purposes — but won't say what it has blacklisted.
Gilbert, the Norwegian volunteer helps out at Shifa several times a year. This time, he brought headlamps, useful for surgeons, but says they are on Israel's list of banned items.
He feels a strong personal bond with his Palestinian colleagues, saying they provide good care under challenging circumstances, but feel hurt by the world's seeming apathy toward Gaza.
Gilbert, 67, is currently the only foreign doctor at Shifa.
"I am not the hero," he says. "These people are the heroes. When we leave, they stay behind."
The employees of Shifa are divided into two categories — those who were hired before the Hamas takeover and those who were hired after 2007.
The former continue to get paid by Abbas' Palestinian Authority. The latter haven't received salaries for several months because of the group's severe financial crisis, a result of Egypt's blockade on Gaza.
Gaza society is split between Hamas and Fatah supporters, with a large group of non-committed in between, but doctors and nurses at Shifa say they're too busy to argue about politics.
The war, which Israel says is meant to halt Hamas rocket fire on Israel communities, broke out during the Muslim fasting month of Ramadan, a time of increased togetherness. Many in the hospital observe the dawn-to-dusk fast, despite their workload.
The sense of crisis has brought colleagues closer together, silencing day-to-day bickering, says Nayef, who hasn't received his salary in months.
"If we work just for salaries, none of us would be here now," he says. "We are here to serve because these patients, they are our families, our friends, our neighbors."