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Background At emergency medical dispatch centres (EMDCs) telephone triage takes place in three steps: identifying the event, assessing the callers' need for support, and prioritizing the response. Some calls are considered to be more difficult to handle than others, and decision support systems may in these situations be of limited help. The aim of this study was to describe and characterize difficult calls to EMDCs. Methods Retrospective call data from 2022 to 2023 was extracted for Registered Nurse (RN) dispatchers at three EMDCs in Sweden agreeing to participate in this mixed-method study. Categories of difficult calls were identified based on prior research and operationalized as key-word searches in the free text call notes or as indicators based on structured data. A purposeful selection of calls meeting these criteria were extracted, anonymized, and data regarding categories and the phase on the call in which they occurred then coded. A descriptive quantitative analysis was performed, and logistic regression was used to estimate the association between demographics and the likelihood of high-priority ambulance dispatch. Results Over the two-year study period, 14 included RNs handled 27,805 calls. Of these, 4888 calls (17.6%) were identified as potentially difficult calls based on free-text notes and structured data, from which 123 calls were selected for further analysis. The median age of callers were 49 years, and 49% were female. Median call duration was 5.6 min, compared to 5.1 min in the full dataset, and 39.5% of calls resulted in a lights and sirens response.Vague or unclear symptoms and psychiatric problems were the most common difficulties. These could occur in all three phases of the calls and in several of the phases in one single call, with a combination of "assessing and prioritizing" being the most common. Male sex was found to be associated with a higher likelihood of receiving an ambulance with high priority. Conclusions Difficult calls, mainly with vague or unclear symptoms and psychiatric problems, are common at EMDCs. The reason for the tendency to prioritize young males higher are seen in other contexts but not in truly high priority cases at dispatch and needs further investigation.