RAFAH, Gaza Strip — Explosions and shootings shook the Gaza Strip’s biggest hospital and surrounding neighborhoods as Israeli forces stormed through the facility for a second day Tuesday. The military said it had killed 50 Hamas militants in the hospital, but it could not be independently confirmed that the dead were combatants.

The raid was a new blow to the Shifa medical complex, which had only partially resumed operations after a destructive Israeli raid in November. Thousands of Palestinian patients, medical staff and displaced people were trapped inside the sprawling complex Tuesday as heavy fighting between troops and Hamas fighters raged in nearby districts.

“It’s very hard right now. There’s heavy bombardment in the area of Shifa, and buildings are being hit. The sound of tank and artillery fire is continuous,” Emy Shaheen, who lives near the hospital, said in a voice message with repeated booms of shelling audible in the background. She said a large fire had been raging for hours near the hospital.

The Israeli military said it raided Shifa early Monday because Hamas fighters had grouped in the hospital and were directing attacks from inside.

Continued Presence of Hamas

The claim could not be confirmed, and the Hamas media office said all those killed in the assault were civilians. But the surge in fighting in Gaza City underscored Hamas’ continued presence in northern Gaza months after Israeli ground troops claimed they largely had control over the area.

Israel launched its offensive in Gaza vowing to destroy Hamas after the group’s Oct. 7 attack on southern Israel. More than 31,800 Palestinians have been killed in the bombardment and offensive since. Much of northern Gaza has been leveled, and an international authority on hunger crises warned on Monday that 70% of the people there were experiencing catastrophic hunger and that famine was imminent.

The mayhem in the north came as Israeli Prime Minister Benjamin Netanyahu repeated his determination to invade Gaza’s southernmost town, Rafah – one of the last major towns not targeted by a ground assault.

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A day earlier, in their first phone call in a month, U.S. President Joe Biden urged Netanyahu not to carry out a Rafah operation, urging “an alternative approach” to more precisely target Hamas fighters there.

Concerns Over Attacking Rafah

The United States, Israel’s closest ally, has expressed concern over attacking Rafah because some 1.4 million people from across Gaza have crowded into the area. U.N. officials have warned of a massive death toll and the potential collapse of the humanitarian aid effort if troops moved into Rafah.

Netanyahu agreed to send a team of Israeli officials to Washington to discuss Rafah with Biden administration officials.

But on Tuesday, he told a parliamentary committee that while he would listen to U.S. proposals “out of respect” to Biden, “we are determined to complete the elimination of these (Hamas) battalions in Rafah, and there is no way to do this without a ground incursion.”

Airstrikes in Rafah overnight destroyed an apartment and several houses, killing at least 15 people, including six women and children, hospital officials said.

New Shifa Siege

The army last raided Shifa Hospital in November after claiming that Hamas maintained an elaborate command center within and beneath the facility. The military revealed a tunnel leading to some underground rooms, as well as weapons it said were found inside the hospital. However, the evidence fell short of the earlier claims, and critics accused the army of recklessly endangering the lives of civilians.

The hospital, which is the heart of Gaza’s health system, was severely damaged in the assault and has only been able to resume limited operations since. Gaza officials say some 30,000 displaced people were taking refuge in the compound when the new Israeli assault began.

The raid came before dawn Monday when tanks surrounded the facility and troops stormed into multiple buildings.

The military on Tuesday said two of its soldiers had been killed in the operation. It said Tuesday that 300 suspects were detained, including dozens it accused of being fighters from Hamas and the smaller Palestinian militant group Islamic Jihad. Some patients were evacuated to nearby Ahli Hospital, said Mahmoud Bassal, civil defense spokesperson.

Abdel-Hady Sayed, who has been sheltering in the Shifa hospital, said troops had rounded up dozens in the hospital’s yard, blindfolding, handcuffing, and ordering them to strip their clothes before some were taken away.

He said those inside, especially men, were afraid to follow Israeli calls to evacuate the hospital. “They tell you to get out, it’s a safe corridor and once they see you they arrest you,” he said. “All are afraid here. The world should do something to stop them.”

The military has identified one person killed in the raid — Faiq Mabhouh, a senior officer in Gaza’s police force, which is under the Hamas-led government but distinct from the militant group’s armed fighting wing. The military said he was hiding in Shifa with weapons, but the Gaza government said he was in charge of protecting aid distribution in the north.

The raid prompted heavy fighting for blocks around Shifa. Hamas’ military wing said it struck two Israeli armored vehicles and a group of soldiers with rockets in the vicinity of the hospital.

Emergency services received multiple calls for help from people whose buildings had been bombed in the streets around Shifa, but rescue teams could not go to the scene because of the fighting, Bassal said.

Kareem al-Shawwa, a Palestinian living about a kilometer (less than a mile) from the hospital, said the past 24 hours had been “terrifying,” with explosions and heavy exchanges of fire. He said Israeli troops had told residents to evacuate the area, but he and his family were too afraid of getting arrested or caught in the fighting to leave their home.

Israel accuses Hamas of using hospitals and other civilian facilities to shield its fighters, and the Israeli military has raided several hospitals since the start of the war.

The Gaza Health Ministry said Monday that at least 31,726 Palestinians have been killed in Israel’s offensive. The ministry doesn’t differentiate between civilians and combatants in its count, but it says women and children make up two-thirds of the dead.

Palestinian militants killed some 1,200 people in Hamas’ Oct. 7 attack into southern Israel that triggered the war and took another 250 people hostage. Hamas is still believed to be holding about 100 captives, as well as the remains of 30 others, after most of the rest were freed during a cease-fire last year.