Rescue workers struggled through strong winds and hail today to locate survivors of the worst tornado in half a century, after 90 people were killed in a small Missouri town.
After a night of terror, Joplin awoke to unimaginable destruction: a vast expanse of splintered trees where entire neighbourhoods once stood, cars flung about like toys.
Sunday's tornado cut a six-mile swath through the centre of town, wrecking churches, schools, businesses and homes. The town fire department estimated up to a third of buildings were damaged or destroyed.
The former mayor, Gary Shaw, described the scene as a war zone. "The trees," he told National Public Radio, "they're like somebody's taken a knife and cut all the bark off of them. We've lost tonnes and tonnes of homes, and we have people out trying to uncover the dead right now."
Some of the worst destruction was at a hospital, which took a direct hit, blowing the roof off the nine-storey building. At least four people were confirmed dead at St John's Regional Medical Centre.
Witnesses said the tornado hovered over the hospital for about a minute, stripping off roofs and blowing in windows.
It is thought 183 patients were in the hospital when the storm warning sirens went off, Miranda Lewis, a hospital spokeswoman, told CBS television. At least four were confirmed dead on Monday .
Nurses told of desperate attempts to move patients away from windows and into enclosed hallways before the funnel cloud descended. Some patients were evacuated on pick-up trucks.
But rescue workers told reporters that many of the patients had been cut by glass after the windows were blown out.
The ceiling of the emergency room caved in. Trolleys were tossed more than five city blocks away, and medical records and s-rays were scattered for 60 miles. Cars were flung out of the car park into a heap.
A helicopter was hurled out of the landing pad, and flipped on its side, its rotors a twisted wreck.
This morning, the hospital looked as if it had been bombed.
"Every window in that building is now broken," Melodee Colbert-Kean, a city council woman, told National Public Radio. "Cars are tumbled all over the parking lot."
Officials said the hospital was now unusable. The seriously ill were transported out of town to other hospitals. Those able to walk were taken to a makeshift ward at a community centre.
Across the southern end of town, an estimated 2,000 buildings were damaged, street signs and other landmarks vanished rendering Joplin unrecognisable to residents who had spent their lives there.
"You see pictures of world war two, the devastation and all that with the bombing. That's really what it looked like," Kerry Sachetta, the principal of a flattened Joplin high school, told reporters. "I couldn't even make out the side of the building. It was total devastation in my view. I just couldn't believe what I saw."
But the scale of damage in Joplin did not begin to emerge until early morning when the city manager, Mark Rohr, held a press conference outside the ruin of the hospital. And there was more to come. Thunderstorms, 60mph winds and in some instances hail stones, slowed the search for survivors.
Meanwhile, the national weather centre forecast violent weather, including tornadoes, all week in Kansas, Arkansas, Missouri and Oklahoma.
Missouri's governor, Jay Nixon, said he feared the death toll would rise as rescue workers began searching the rubble for survivors and bodies. "I don't think we are done counting," he told reporters.
But he said he remained hopeful of finding survivors in the rubble. "I still believe that because of the size of the debris and the number of people involved that there are lives to be saved."
As rescue workers moved out to look for survivors in the rubble, fires from gas leaks burned across the city. Downed power lines blocked roads.
Nixon said he had reports of 15 missing elderly residents from a care home. The website of the local paper, the Joplin Globe, carried messages from people searching for loved ones.
And with phone services down, dazed survivors tried to make their way through streets blocked by debris to look for relatives. Outside a mound of debris that was once a shopping mall, Justin Gibson pointed to a black pickup truck tossed into the ruins of a hardware store that he said had belonged to his room mate's brother.
"He was last seen here with his two little girls,", Gibson told reporters. "We've been trying to get hold of him since the tornado happened."
But there were also triumphs. Search crews pulled people from the rubble of a local Wal-Mart and a hardware chain.
Sunday's twister was the second deadly tornado event in less than a month.
About 350 people were killed after an estimated 200 tornadoes ripped across Alabama and five other southern states.
The storms set a record for the deadliest single tornado event, but even that has been eclipsed by the devastation in Joplin, a town of around 50,000.
It was the town's misfortune to take a direct hit from the tornado. "If the Joplin tornado had struck 10 miles north, we wouldn't be hearing about it, but it went right through the centre of town," said Robert Henson, a spokesman for the University Corporation of Atmospheric Research.
Still, said Josh Wurman of the Centre for Severe Weather Research, the tornadoes could have inflicted even greater casualties and damage. "What if this had gone through St Louis or Oklahoma City or Chicago instead of Joplin," he said. "The potential consequences would have been much worse. It would kill many more people and destroy many more structures."