Background: This study explored the emergency medical service (EMS) in rural mountain areas in Taiwan to establish the public health policies in rural mountain areas. Methods: This was a retrospective study. Based on mission records available at 3 EMS branches in Ren-Ai and Sinyi townships of Nantou County, we evaluated dispatched status, patient characteristics, and pre-hospital emergency managements. Results: From January to June 2011, a total of 765 EMS were dispatched from these 3 mountain branches. Each dispatched EMS team was consisted of one official emergency medical technician (EMT) with EMT II certificate (100%), and one (88.0%) or two (11.2%) volunteers as EMT I personnel. Most of missions were conducted in the daytime and peaked during 10am to 12pm. Patients were characterised with more men and elderly and predominant with non-traumatic medical complains (55.0%). Approximately 38.7% EMS patients required the advanced life support. Of these 3 mountain EMS branches, the mean response time was 15.3+/-16.9 minutes, the mean management time on site was 6.1+/-6.9 minutes and the mean transport time was 38.0+/-15.9 minutes. The response time and transportation time of EMS in rural mountain areas were relatively longer than that in urban towns in Taiwan. Conclusions: The rural EMS is under the challenges of providing appropriate and adequate medical care. Each EMS team should be equipped with adequate emergency care facilities and well trained personnel.