Ambulances in Taiwan have always been viewed by medical personnel and the population at large purely as transport vehicles. The emergency medical services (EMS) system upgrading will require a change of concept. Following emergency medical technicians (EMT) training in Keelung, a 400000-inhabitant mid-sized port city in northern Taiwan, we began prospective data collection to evaluate the patterns of ambulance use, misuse and potential needs within the community. Over a 3-month period, 1035 calls, 572 fully documented patient transfers and 17703 emergency department (ED) visits at the city's largest hospital were collected and analysed. The daily call volume was 0.32 per 10000 population with 31.7% of all ambulances dispatched resulting in no patient being transferred. The majority of patient transports were for trauma (61.2%), with almost all of the no patient transfers also following trauma, having been called in by someone passing by or witnessing the accident. Of those transported, 27.6% did not require even basic EMT care and so were considered misuse. Conversely, the majority of critically ill patients presenting to the hospital ED did not arrive by EMS ambulance, giving a conservatively projected unmet need of 86%. Despite low call volumes, misuse and non-transport, rates appear high. This is because the majority of accidents are called-in by passers-by who have no first aid training and a cultural aversion to becoming involved. At the same time unmet needs are also high, with education required to get the public to change their practice, and further study needed to see if this will, in fact, improve outcomes.