Gaza resembles "something out of a Mad Max movie", with lawlessness on the streets and amputations carried out on children daily, an Irish surgeon who left Palestinian territory this week has said.
Dr Morgan McMonagle, a University Hospital Waterford consultant vascular and trauma surgeon, spent the past three weeks working at Nasser Hospital in Khan Younis. He worked in the enclave on two previous occasions.
Despite the US-backed ceasefire which started on 10 October, Dr McMonagle told RTÉ's Morning Ireland the situation in Gaza is as bad as ever.
Speaking ahead of his departure from Gaza, he said: "I don't know if you heard in the background, there's an F-35 airplane flying over me at the moment. There are still reconnaissance missions going on. We have the constant drone noise - that's 24/7. We're hearing explosions every single day," he said.
On his first night back in Gaza, there was a mass casualty emergency. Most of the dead and injured were hit by shrapnel.
"We were given a security warning that Israel had made a decision to bomb various parts of Gaza, which then happened, and we had a mass casualty incident at about 3.30-4am in the morning. We had, I think the figures were, 23 dead that night, and I think about 60 or 65 severely injured. There were operations going on all night," he said.
"Of the 23 brought in dead that night, I think about 13 or 14 were under the age of 18.
"They were mostly shrapnel injuries. That’s because if you're close enough to the epicentre of a military-grade explosion, you're effectively dead, due to the power of the actual explosion itself.
"So, most of the people who arrived alive with shrapnel injury, the problem with shrapnel is you've got hundreds of pieces of metal and cement and grit going at supersonic speed. It’s never a single system injury. So, it'll affect your brain, your chest, your abdomen, your limbs.
"So, for example, a 14-year-old girl who we operated on ended up with major vascular injuries to her lower limb and her upper limb. She also had penetrating injury of her brain and her belly. Two days later, I did an amputation of her leg, and three days after that, she died.
"From my experience, if you receive shrapnel penetrating injury to the brain, from my experience, it is almost a 100% mortality injury," he said.
"It is like something from a Mad Max movie where a post-apocalyptic disaster has occurred. The difference being, of course, this is completely man-made"
In recent days Dr McMonagle, who is originally from Cavan town, amputated a 14-year-old boy's leg. The boy's dreams of playing with Manchester United died with the life-saving procedure.
"It's never nice, amputating a limb of a child. I did one yesterday, a 14-year-old boy who received a gunshot to his leg, we repaired the vessels. Didn't work, his leg died, took off his leg yesterday. I saw him this morning, he's doing very well.
"He's just lost his leg and he was a keen soccer player. He told me through the interpreter he wanted to play for Man United. You know, it's unlikely he'd play soccer again because it's what we call an above-knee amputation, so he's lost his knee. But children are children and he seemed reasonably happy to see me this morning.
"His parents were naturally very upset. But again, this is a recurring theme."
"And I've done many, many amputations of children, all in Gaza, all in Gaza, all due to either gunshot wounds or shotgun injury. All man-made," Dr McMonagle said.
He also said the conditions in Nasser Hospital are difficult with infection and disease being rampant.
"The actual disease and the infectious diseases in the hospital is absolutely enormous. You walk on the ward and it's like something from the 18th Century from a plague hospital because there are patients everywhere and families lying on the floor, lying in the stairwells.
"You can smell, there's a particular infection that comes with wet gangrenous wounds called pseudomonas. Some of your listeners who are healthcare workers will know the smell. The wards constantly have that hanging thick in the air. There's infection everywhere.
"And on top of that, they just come out of a period of starvation. So, their body's immune systems are not good at fighting infections or fighting wounds. So, wounds break down. And this is a problem over and over and over again," he said.
Medical supplies remain in short supply because they are not allowed into Gaza, he said.
With painkillers and anaesthetic scarce some patients feel pain during procedures, Dr McMonagle said.
"We're getting by, we're making do. But Israel have banned medical supplies coming in. You compromise. You find whatever's available and you compromise. It's not ideal and patients are left in pain," he said.
On other supplies and food getting into Gaza, he said there is a lack of protein available to people.
"Food is trickling in. There's enough carbohydrate, well, I can see in the form of rice getting in. But that's about it ... and now that we're heading into the winter, things are going to get colder. Everyone's living in tents outside the hospital now," he said.
"I've seen a lot of children come in with the hallmarks of a period of malnutrition, so they've lost a lot of weight. They're very, very thin. The staff, who I remember last time, have lost weight. So, I would say there's a trickle of feed getting in, but not enough. And it's mostly in the form of carbohydrates. So, it's rice, it’s potatoes, it's not protein," he said.
Comparing Gaza today to what he saw when he was last there in March, the Waterford doctor described it as a wasteland where people live in tents beside rubbish dumps and open sewage.
'There's infection everywhere".
"My best description is that it's like something from a Mad Max movie. There's very little law and order. The buildings, those that are even standing are still badly destroyed. And you can see people have moved into them and put up some tarpaulin or put up some blankets to try and protect them from the elements.
"But most people are living in tents. And therefore, there's makeshift sewage, which is going into various holes. People living beside dumps that's full of rubbish and putrefying flesh.
"There's dogs and cats everywhere. When we arrived here, we were told, and we've been told several times ... to concentrate on the living children and the living women of fertile age, because people know there's a genocide going on. People know that certain nationalities want to raze the Palestinians as a race.
"It is like something from a Mad Max movie where a post-apocalyptic disaster has occurred. The difference being, of course, this is completely man-made.
"It looks like a ... a jungle of concrete wreckage. That's the best way to describe it," he said.
Talking about the sense of security in Gaza he added, "there's very little official law and order. Law and order has broken down and it's a conflict zone. So, people are naturally struggling to survive".
Asked what the local view is of the ceasefire, he said people see it as "a pause".
"Most locals just say what you'd expect. We hope this will hold. We pray it'll hold. But they don't believe it's a ceasefire. They call it a pause. It is and it isn't because there's still bombs going off, there's still shootings, there's still quadcopters and drones in the air, there's still F-35s flying over."
