Miranda Pederson/Daily News Rick Beliles, a communications specialist and paramedic with The Medical Center EMS, uses Priority Dispatch to keep track of where ambulances are.

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Until recently, a state regulation stipulated how ambulance service workers determine where a patient should be treated.

Patients able make that decision were given a choice; if not, a physician made that determination, and lastly, it was left to emergency services workers.

Now it’s a judgment call by EMS, according to Mike Swift, director of the Barren-Metcalfe County Ambulance Service.

But Swift said his EMS workers still try to honor patients’ requests due to insurance or other matters.

The same is true for The Medical Center EMS, according to Doris Thomas, vice president of Commonwealth Health Corp., the service’s parent company.

“While we are not required to ask the patient what hospital they wish to go to, we have always given the patient a choice when possible,” Thomas wrote in response to Daily News questions.

Swift said there are other things to take into consideration when following patients’ wishes.

“If it’s a true medical emergency ... we go to the nearest hospital first,” he said.

But there is a big exception to that rule.

Sometimes hospitals aren’t equipped to handle a particular kind of patient. Swift said, for instance, his drivers know that if the patient will need immediate surgery, T.J. Samson doesn’t have a surgeon available on the weekends, so the patient will be diverted elsewhere.

There are other reasons that patients would have to be diverted elsewhere.

When there are a large number of patients injured in an accident, for instance, emergency workers will try to keep family members together, rather than sending them to separate facilities, Swift said.

And over the winter, for instance, T.J. Samson had many of its beds filled with flu cases and ailing older patients, so drivers knew in advance when beds weren’t available, he said.

In all, about 7,000 runs were made last year, with at least 1,000 of them going to medical facilities outside Barren and Metcalfe counties, according to Swift.

Patients were taken to a variety of facilities, including The Medical Center, Greenview Regional Hospital, hospitals in Louisville and Nashville and elsewhere.

In Warren County, The Medical Center’s EMS makes about 15,000 runs annually, with Greenview Regional Hospital getting about 1,300 ambulance arrivals a year from all sources.

When a tour bus crashed on Interstate 65 in Warren County in June, 44 people were taken to The Medical Center, two were taken to Vanderbilt University Medical Center in Nashville, 14 were taken to T. J. Samson and six were taken to Greenview. Two Medical Center patients were eventually sent on to Vanderbilt.

How was such a decision made at the time?

Ronnie Pearson, director of Warren County Emergency Management, wasn’t at the scene of the accident but said in such large scale incidents with multiple agencies involved, typically a unified command system is used to control the situation.

That system involves someone from law enforcement, EMS and emergency management.

“The command jointly makes the decisions on this scene,” Pearson said.

Kentucky State Police Trooper Todd Holder, however, said such a command wasn’t used.

“There was a staging area for people to be looked at, but there really wasn’t a command post,” Holder said.

Thomas said the EMS team set up its own incident command system and patients were triaged at the scene, contacting hospitals to see how many patients they could accept.

Greenview Regional Hospital CEO Mark Marsh said there apparently was some miscommunication with that incident, with the EMS believing that Greenview could only take four or five patients at the time.

Thomas wrote that Greenview was called twice and said initially it could take three to four patients and later said they could accept two more.

The Medical Center said it could accept 24 patients but also received some people who were not injured or only slightly injured to be near family, she said.

But it’s other incidents, when accidents happen within sight of Greenview and patients go to The Medical Center, that Marsh said concern him.

In addition to seeing patients from accidents near Greenview go to The Medical Center, Marsh said he’s had board members tell him that they have witnessed accidents within a 1/2 mile of The Medical Center being sent to Greenview, and many of those patients end up being uninsured.

Thomas said that 75 percent to 80 percent of the EMS patients request The Medical Center.

“The percentage of EMS patients that request to be taken to The Medical Center is consistent with the percentage of people who choose The Medical Center for their care,” she wrote.

With 10 beds and another holding area for eight more, Marsh said Greenview’s emergency room is well equipped to handle nearly all emergencies and does.

It handles about 18,000 patients in the emergency room annually, with a turnaround time of less than two hours.

Marsh said he’s been told that some patients have to wait four or five hours in the ER at The Medical Center for treatment.

“Why not send some of those EMS patients our way?” he said.

Thomas, however, said that patients are triaged within seven minutes of arrival.

“It takes about three and a half hours after a patient arrives in the ER to receive treatment and to be discharged,” Thomas said.

“There are many factors that go into wait times - for example some situations require several different tests and procedures, excess volume due to multiple traumas and the number of patients that use the ER for primary care, and we never turn anyone away.”

The Medical Center, following an expansion in 2003, has 28 private rooms in the emergency department and currently serves about 43,000 patients annually, according to Thomas.

In other incidents, Presidential Directive No. 8 under the National Incident Management System requires that all first responders have specific training, Pearson said.

“The very first responder on the scene is considered the incident commander and he can roll that responsibility over to the next agency in charge as the incident escalates or de-escalates,” he said.

“For instance, if a tractor-trailer rolled over on I-65 and there was a diesel spill, KSP might be the first responder on the scene,” he said. “Then if the victim is trapped, the ambulance and fire department responds and it becomes a medical incident. ... Once they get the victim out, the fire department takes over and if there is no longer a fire hazard, someone from our office or Natural Resources would take over to clean up the spill.

“Typically, whatever is the incident’s highest priority is usually the lead agency.”

In responding to accidents without the severity of June’s bus crash, emergency personnel ask victims, if they are conscious, which hospital they would like to go to, according to KSP spokesman Todd Holder.

“And they actually record their response,” Holder said. “If the patient is unconscious, I guess EMS would decide that.”

Marsh said that even when patients are asked where they want to go, seeing a vehicle that says The Medical Center and an EMS worker’s uniform with The Medical Center on it can influence their decisions.

“Patients need to be more informed of their choice,” he said.

Marsh said his hospital and emergency room have tried to work with the EMS, which is owned by the competing hospital, and “for the most part those are good guys.”

So why doesn’t Greenview operate it’s own ambulance service?

“I’m not saying we would or we wouldn’t,” Marsh said, noting the expense to operate a service. “But we have had conversations with private companies that would be interested in operating one.”

But the problem with that is Kentucky’s certificate of need process, he said.

That process involves an application to the state and allows for public comment, protests and a hearing if needed.