Shots crack through the air and tear gas canisters explode all around, leaving the road barely visible. "Live ammo, live ammo," the radio crackles. The rear doors of the ambulance swing open and a writhing youth is hurled inside.
"Go! Go! Forward! Go!" paramedic Nader Morrar shouts as the emergency vehicle speeds though the smoke toward the hospital, sirens blaring. He tears the young man's jeans to get a better look at the wound. "We've got a .22 [caliber bullet] through-and-through," he radios back.
It's the type of scene that has become a near-daily occurrence in the West Bank and Jerusalem as a wave of unrest — including violent protests and a series of stabbing and shooting attacks by Palestinians against Israelis — threatens to become a Third Intifada.
Protesters, many just teenagers, bait Israeli security forces by burning tires and hurling rocks in slingshots. The response usually comes in the form of a hail rubber bullets, tear gas, and the occasional sniper shot.
Medics and ambulance staff pick up the pieces. Earlier this month, the Palestine Red Crescent, a national humanitarian organization that provides frontline medical aid to the wounded, declared a level three state of emergency amid the escalating violence. Since then, the NGO has treated more than 4,000 wounded, including 279 injured by live fire and 1,070 by rubber bullets.
A total of 19 Palestinian protesters, including a 13-year-old boy, have been killed during clashes with Israeli security forces since the recent wave of unrest begun, mostly from live ammunition.
When he receives a casualty, Morrar, who trained as a medic after he was shot in the leg at a protest 10 years ago, has to make a quick decision on how and where to deliver treatment. There are two categories he says, "load and go or stay and play," meaning they can either offer treatment at the scene or take the victim to a hospital.
Related: Locking Down Jerusalem: Intifada 3.0
Quickly making the right call can mean the difference between life and death. With live rounds in play, an all-hands-on-deck situation could happen at any moment, meaning ambulances shouldn't leave the scene of clashes unless it is deemed absolutely necessary to treat the patient. But on the other hand, failing to move someone who needs urgent hospital treatment could result in a preventable fatality.
"Time is everything in these situations," says Morrar. "There is just seconds to assess and decide what to do."
The decisions are easy in some cases. Mahmoud Fadel, 21, took a "through and through" bullet to the lower leg, meaning the projectile passed through his body and is not lodged inside him. The ambulance heads immediately to the hospital while Morrar stabilizes the patient, monitors his vitals, and inserts a catheter for the doctors at the hospital to administer pain relief.
Other cases are more complex. At around 3pm, a man named Abdullah is helped into the ambulance by his friends. Blood trickles from a deep gash in his head. At that moment, Abdullah can talk and walk without assistance. "I'm fine," he insists. Morrar does a quick examination and decides otherwise. His call turns out to be a good one.
By the time the ambulance reaches the doors of the emergency room at Ramallah Medical Complex, Abdullah is semi-conscious. Hospital medics take him straight to the resuscitation room and close the doors.
"You can have all kinds of complications happening," explains Morrar. "Maybe somebody has an allergic reaction to gas, maybe they have a heart condition you don't know about it. If there's a bullet inside someone or a head injury you don't know what's going on inside. So you have to be aware that there's a lot you don't know about the person that's being treated, an injury might seem light but there can be quick deterioration of the patient's condition."
To ease pressure on hospitals and ambulances, the Palestine Red Crescent has established a field hospital a few hundred meters from the clashes in Ramallah. Here, in the parking area beneath a block of apartments, medics are on standby to treat those that need to be evacuated from the scene but aren't seriously wounded. Patients are treated on mattresses laid out side by side on the concrete.
"It looks kind of rough," says Morrar, "but it really saves time and resources. It's a very effective way to do things."
Mad dashes to pick up wounded from the frontline of the clashes means medics are often right in the firing line, and some end up becoming patients themselves. "If someone falls over in the middle of things we can't leave them there," Morrar explains. "Then we have to cross between the two sides and pick them right up, then get out again."
One of the most risky jobs is working on the first-response teams, whose job is to pick up the wounded, wave over ambulances, and help move people inside on stretchers. At around 4:30pm, Morrar's ambulance picks up a volunteer medic who has been shot in the lower leg twice with a rubber bullets while trying to reach a wounded protester.
The Palestine Red Crescent says that Israeli security forces have not done enough to avoid hitting medical staff in the crossfire, and that they have attacked or prevented humanitarian workers from doing their jobs. In total, the organization has recorded 39 injuries to staff, 31 cases where ambulances were damaged, and 26 incidents of restricted access.
Human Rights Watch has also complained that one of its workers was hit by rubber bullets while documenting what was at the time a peaceful demonstration.
Over the course of the day, the crew in Morrar's ambulance treats 12 people for tear gas inhalation — including two cases with serious complications — three people for injuries caused by rubber bullets, two people hit by live ammunition, and one person who was hit by a stone, an incident he refers to as a "friendly fire case."
'Everybody is alive today, that's the most the important thing'
Some of those who get into his ambulance are familiar faces, including one youth who was shot in the foot with a live bullet only last week. Several refuse hospital treatment, preferring a quick clean up of their wounds so they can return to the clashes outside.
As night falls, the protesters begin to drift away. The Israeli soldiers retreat and the mood in the street becomes celebratory as the youths hang out in a nearby playground and buy snacks from a shop that has re-opened.
As he prepares to go home, Morrar declares the day a success. "Everybody is alive today, that's the most he important thing," he says. "Tonight home for a hookah… and tomorrow we'll be back. Inshallah [God willing] it will be another successful day."
Follow Harriet Salem on Twitter: @HarrietSalem