Objective This study aimed to explore emergency medical dispatchers' (EMDs') experiences of prioritising patients and stewarding ambulance resources when system capacity was constrained.Design Qualitative interview study using inductive qualitative content analysis.Setting Emergency medical communication centres (EMCCs) in Sweden, operated by the national emergency call provider and responsible for receiving 112 calls and dispatching ambulances.Participants 13 purposively sampled EMDs with at least 1 year of professional experience.Data analysis Interviews were analysed inductively using qualitative content analysis (Elo and Kyng & auml;s) through open coding, grouping into subcategories and abstraction into generic categories and one main category.Results Dispatchers described prioritisation under scarcity as system work that simultaneously addressed individual patient acuity and population-level readiness. One main category captured this work: stewarding scarce response capacity. Three inter-related generic categories characterised stewardship: (1) prioritising by clinical urgency within geographic and operational constraints; (2) producing availability through anticipation, reassessment and queue governance in a 'virtual waiting room'; and (3) coordinating response through information infrastructures and interprofessional collaboration. Across categories, dispatchers described redistributing risk across patients and time, managing moral strain when delays could harm patients and using experience, reassessment and teamwork to avoid both under-response to urgent need and over-allocation that would leave areas without coverage.Conclusions Dispatch under scarcity is best understood as active stewardship of a safety-critical dispatch queue. Strengthening patient safety therefore requires organisational support for reassessment and escalation during prolonged waits, explicit governance of queue dynamics and geographic coverage trade-offs, safeguards for contextual judgement when automation is used and support for dispatchers exposed to morally difficult scarcity decisions.