As Gazans face widespread starvation, doctors in the enclave say they have been treating victims of mass shootings almost daily after crowds of Palestinians seeking food are fired on. Witnesses say Israeli troops have frequently shot at people who pass near military positions while approaching aid sites or who throng relief convoys.

More than 1,778 Palestinians have been killed and more than 12,894 wounded under these circumstances since late May, according to the Gaza Health Ministry, which does not distinguish between civilians and combatants.

International aid agencies say that the scale of the bloodshed has pushed an already buckling health care system practically to the breaking point, as medical workers scramble to treat the tide of casualties - at times on the floor - and hospital staff use what downtime they have to find extra beds and surgery teams for the next influx.

The following description of the conditions inside Gaza’s hospital wards is based on interviews with seven American and European medical workers who visited Gaza as part of voluntary medical missions between May and the first week of this month.

Each medical worker said that the Israel military’s bombing of medical facilities in Gaza during the ongoing war with Hamas, combined with a near-total blockade of the enclave since the winter, has often made it impossible for doctors to deliver adequate treatment. A shortage of oxygen tanks has forced staff to choose whom to save, medical workers said, and a dearth of wheelchairs and crutches at times forces families to carry away disabled relatives in their arms.

Many of the victims have been shot in areas near food distribution sites run by the U.S.-backed Gaza Humanitarian Foundation (GHF), according to aid groups and doctors treating the casualties. But Palestinians have also been killed while trying to pull flour from United Nations convoys or while waiting for aid drops from the sky.

The Israeli military has issued statements saying it fired “warning shots” toward “suspects.” In response to a request for comment, the Israel Defense Forces said that reports of civilian harm had resulted in new instructions being issued to troops “following lessons learned.” In a statement Saturday, the GHF said it was “constantly adapting our operations to maximize safety for civilians and aid workers.”

At Nasser Hospital, the largest medical center still functioning in southern Gaza, doctors and nurses said they were repeatedly jolted awake by what is known as the mass casualty alarm: a siren that warns of the coming deluge. “You’re hearing: ‘Any doctor who is available, please come down to the ER,’” said Aziz Rahman, an American intensive care specialist from Milwaukee who visited Gaza on a medical mission with Rahma Worldwide, a humanitarian group based in Michigan. “Pretty much every day the aid sites were opened, we saw shootings.”

Three doctors who worked in the emergency room at Nasser Hospital said gunshot wounds suffered by their patients were mostly in the head, heart or lungs. On June 24, Rahman recalled, one of his patients was a 9-year-old boy shot in the spine.

In the Red Crescent clinic in southern Gaza, Rieke Hayes, an Irish volunteer physiotherapist, said her patients had been shot in their legs, and arms, and sometimes in the back. She said some of the victims were teenage boys who had been shot as they were walking away from distribution sites after finding that all of the food was gone.

Gaza has been under near-total siege by the Israeli military for six months, and the world’s leading hunger monitor, the Integrated Food Security Phase Classification, now says that the worst-case scenario of famine is playing out. At least 217 people have died of malnutrition or starvation, according to the Gaza Health Ministry.

The GHF’s four aid distribution sites are inside areas controlled by the Israeli military, and large crowds gather near them most days in hopes of securing the first-come, first-served aid supplies when the sites open. Inside the Red Cross’s 60-bed field hospital in Mawasi, located on the coastal road to the city of Rafah, medical workers said they often heard the crowds pass as they headed toward GHF locations.

“If the food distribution center opens at 6 a.m., the mass-casualty event starts at 4:30,” said Hayes, who worked there during GHF’s first five weeks of operations. “If it opens at 12 o’clock, the injuries start coming around 10 a.m.”

She said mass shootings took place almost every day of her medical mission after the GHF sites opened in late May. On some days, the Red Cross clinic has received more than 100 victims, according to the clinic’s log. Doctors at Nasser Hospital likewise reported that casualties have exceeded 100 on some days.

The worst day of Rahman’s two-week medical mission was June 17. “The traumas went on for four to five hours. They just kept rolling in,” he recounted.

Doctors said they tried not to slip on the blood between patients they triaged on the floor. Nasser’s hospital staff tried to sweep it down tiny drains, but with each new patient, the floor just reddened again, Rahman recalled.

The trek to GHF distribution points is frequently long and arduous, so Palestinian families often send their most able - usually teenage boys and young men. But with tens of thousands of Palestinians having been killed and maimed during Israel’s military operations in Gaza, not every family has that choice. The Red Cross says its doctors have treated women and toddlers for gunshot wounds, too.

In quieter times, Hayes said, she had known all of her patients’ names. As a physiotherapist, she worked on teaching the wounded to walk again. One of the patients she remembered best was an 18-year-old, Ahmed, who had been wounded so badly in an explosion weeks earlier that he had lost the use of all but one limb. He was there every day with his brother Mohammed, 20, who became his caregiver. “It was a challenge to get him out of bed, but he did it,” she said. “He would put his one good arm around his brother and just hop.”

Amid the chaos one day, she said she heard an elderly couple calling her name. It was the boys’ parents, begging her to help Mohammed. “And there he was, lying with a bullet hole to his neck and his shoulder, and his mother is crying in my arms and asking me to do something,” Hayes recalled. The young man’s parents told her he had gone out to find aid and been shot.

At Nasser Hospital, Mark Brauner, an American surgeon from Oregon, recalled one day stepping out of the ER for water and being taken aback by what he saw. “I walked out and there were just lines of bodies and people that had severe injuries that would have met the criteria for the trauma resuscitation room,” he said.

When the casualties finally stop coming, Brauner said, “you wash away the blood, sit there for a few moments stunned, and then it might happen all over again.”

Gaza’s doctors were exhausted long before the shootings began outside the aid distribution centers. But more recently, even when the stream of casualties slows at night, medical workers said more toil begins: tending to other patients, and in some cases preparing other hospital rooms and even tents to handle the overflow from the emergency room.

For Nour Sharaf, an emergency room doctor from Dallas, the worst day was July 20. She said al-Shifa Hospital in Gaza City, where she was working, received 1,024 patients that day. “You just don’t have enough time to see that many patients,” she said. Many were malnourished, and Sharaf said she could feel the bones of every patient she treated.

Most had come that day from near the Zikim border crossing, where witnesses said Israeli troops opened fire on large crowds trying to loot trucks of U.N.-supplied aid. The U.N. World Food Program said its convoy had “encountered massive crowds of hungry civilians which came under gunfire.”

The Israel Defense Forces said in a statement that it had identified “a gathering of thousands of Gazans” and fired “warning shots” to “remove an immediate threat” to troops.

The next day, Sharaf’s team received a young boy who had been shot in the head near Zikim and would soon die, she recounted. No one knew who he was until his family arrived, frantic, two days later. They said he had been missing. When they had noticed their water jugs were also missing, they realized he must have gone to fetch scarce water. Sharaf said he was carrying the jugs when he was shot.

Heba Farouk Mahfouz and Siham Shamalakh contributed to this report.

previous coverage

• Netanyahu defends new military offensive in Gaza and says it will be wider than announced
• Israel faces growing condemnation over military expansion in Gaza
• Germany halts military exports to Israel for use in Gaza amid outcry over Netanyahu plan
• US backs Israel’s ‘tough decisions’ over Gaza, Ambassador Huckabee says