This is the misery of Misrata, where four months of grinding siege have left a nearly cashless economy based on charity, camaraderie and revolution.

It is an atmosphere of hardship and heartbreak. Over half the city lies in ruins. Brothers, fathers and sons from almost every household risk their lives defending the city from the forces of Colonel Muammar Gaddafi which surround it. Day and night attacks from Grad ground-to-ground rockets claim victims indiscriminately. The hospitals are overwhelmed, attending to an average of 70 casualties a day. Fear and mental anguish are also taking a toll.

Since fighting erupted in the streets of Misrata on February 17 - between troops loyal to Colonel Gaddafi and anti-government rebels - Misrata has been torn apart by war. About 1200 of the city's inhabitants have been killed and more than 8000 injured. Hospital staff say that about 40 per cent are civilians.

''For me all of them are civilians because even those who take a gun are businessmen, engineers, students - none of us are soldiers,'' Dr Aiman Abushahma said as he attended patients at al-Hekma, formerly a private clinic that receives the majority of Misrata's casualties since the city's main hospital was damaged several months ago. ''We only take up arms because we have seen what Gaddafi has done to us.''

The sound of ambulance sirens interrupted Dr Abushahma's comments. A new group of casualties began to pour in from the frontline after the strongest push forward by the rebels in weeks. Tents set up in the car park cater to new arrivals. Volunteers line the entrance waiting to unload the dead and injured from the constant flow of ambulances. Children stand by, eager to do their part by hosing the blood from the roadway in between each rush of patients.

Over the past four months, doctors have been working day and night with little sleep and no pay in dire conditions with limited supplies. In the hospital's intensive care unit a medical student, Abdol Fattah Salem, 24, was working with three patients in an overcrowded room at 4.15pm on Wednesday.

''My shift ended at 9am this morning,'' he said, showing no signs of slowing down any time soon. ''One of the doctors fainted from exhaustion yesterday after working 24 hours straight. When he came to, he got up and kept working.''

Inadequate and outdated equipment coupled with a constant lack of vital medications is a continuing struggle. The only supply route is by sea and shipments of medical supplies and boats to evacuate the wounded face constant delays. Anas Ragab, a spokesman for the Medical Supply Committee of Misrata, said that adding to the problem of getting drug supplies into the besieged city is the rate of consumption.

''Currently in three days we consume the usual supply for an entire month,'' he said. ''We often run out completely.''

Permanent injuries are common. More than 400 patients have undergone amputation. Many others will heal in time but the psychological impact the conflict will have in the long term is also of deep concern.

The empty stare of Fatima Abdullah Aladjer, 35, spoke volumes as she lay in her hospital bed on Sunday morning, disfiguring burns covering her face and body. She had given birth to her third son that morning when a rocket launched from the eastern frontline tore through her home, instantly killing her oldest son, 15-year-old Mohammed, and severely injuring her and 12-year-old Farag as they prepared a meal.

Farag lost several fingers and toes and suffers from severe burns from head to foot. He mindlessly operated his remote-control car back and forward through the hospital ward with his bandaged fist.

Ahmed Sewehli, who returned from Britain three weeks ago to head the newly-formed Misrata Psychiatrist Department, said signs of post-traumatic stress and depression are escalating.

Dr Sewehli recalled one severely disturbed patient, a mother of three, who was locked in a car with her three children and used as a human shield by Gaddafi's troops to block incoming rebel fire. Others have had loved ones blown to pieces in front of them, or die in their arms.

''The things they have witnessed and lived through will have a big effect not only on the women and children but on the men on the frontline as well,'' Dr Sewehli said. He spoke of the difficulties these men will face when they return to a normal life. '

'I am particularly concerned for the children; violence and death is becoming normal for them. When the fighting is over, the thing that worries me most is the possibility of an increased tendency towards violence.''

Gazala Ali Karim, 53, is part of a group of volunteers who have set up temporary schools to provide activities for the children, giving them some semblance of normal life. She says many are still traumatised by the constant sound of distant bombs and gunfire. All have relatives, fathers, brothers fighting on the frontline and even the youngest have seen enough to understand the very real chance that they may never return, she said.

''At first, even at the sound of a door slamming, many of the children would cry and scream,'' Mrs Karim said, thumbing through drawings of tanks firing, bodies coloured with red blood and Gaddafi being executed, all drawn by the children in art class. ''The activities have helped but most still have nightmares.''

Amid the heartbreak he has seen, Dr Sewehli said he has been deeply moved by the ''resilience'' and ''togetherness'' of the community.

Since the fighting began four months ago, Misrata has been functioning with virtually no wages being paid, yet the city continues to function thanks to volunteer labour. ''The nightmares and fear will continue for many years to come, but I see a great determination in this city to make Misrata a better place,'' Dr Sewehli said. ''I admire the resilience and faith of those who have lost loved ones. When this is over, I do believe Misrata will become a great city.''