Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

You had me at ‘Controversial post for the week’ – Part II

In Part I, I started to look at the kind of trouble that an Ambulance Chaser would be up to.

Waveform capnography was one of the recommendations that the AHA (American Heart Association) has not effectively stressed.

What else does Ambulance Chaser state has been neglected by the AHA?

What about dual defibrillation? Therapeutic hypothermia initiated during the arrest? Mechanical CPR devices?[1]


Was there good evidence that these treatments improved survival before the 2010 guidelines were written?

Is there good evidence now?

We have enough problems with wishful thinking-based treatments already. We should not be adding to the problem. These treatments should only be used as part of well controlled studies.

The “everyone gets a card” mentality means that the current courses have become another example of the “everyone gets a trophy” mentality that permeates our country right now.[1]


We have a problem with people who do not understand science claiming that their politics, feelings, opinions, et cetera are as good as valid science.

Image credit.

We are plagued with climate change denialists, vaccine denialists, evolution denialists, moon landing denialists, 9/11 truthers, and other conspiracy theorists who want their wishful thinking participation trophies.

We have been lowering the standards in America so that every conspiracy theorist can get a preach the controversy participation trophy.

These are not controversies.

Would we let these conspiracy theorists fly a plane we are traveling on, fix our vehicles, grow our food, or do other things that do not require advanced science education?

No, but we put our heads in the sand and pretend that their ignorance is as good as the valid research of the best scientists we have.

Here’s your participation trophy.

In fact, if I was a medical director, the only card courses I’d require would be Advanced Medical Life Support (AMLS) and PreHospital Trauma Life Support (PHTLS). Those are courses designed for EMS providers and based on assessment, not blind parroting of rote, already dated protocols.[1]


PHTLS (PreHospital Trauma Life Support) still encourages the use of backboards and discourages research to find out if there is any decreased disability with use of backboards, any increased disability with use of backboards, or if the benefits and harms are roughly even.

We don’t know and we don’t want to know, because as long as we cannot prove that there is increased disability, we can have our wishful thinking participation trophies. 😳

This is dangerously irresponsible, but it is what happens when wishful thinking becomes more important than valid evidence.

Perhaps it has not been demonstrated safe but it has never been demonstrated unsafe either. Better stay with the known than go to the unknown. If you want to develop a research project, please go ahead and do it. But without proof that they are bad, we cannot just assume that they are bad.


We are irresponsibly assuming that backboards are beneficial, as we did with blood-letting (how many did doctors bleed to death?), prophylactic post-heart attack antiarrhythmics (estimated 60,000 dead), dumping fluids into patients with uncontrolled hemorrhage (how many did EMS kill?), . . . .

Assuming that something is beneficial may be OK – as long we are the only ones assuming the risk.

We are not the ones assuming the risk. Our patients are the ones injured by our hubris.

We appear to have abandoned ethics in favor of wishful thinking.

It’s time EMS progresses beyond rote memorization and embraces assessment-based interventions and sound science. Kudos to those EMS medical directors and EMS systems who’ve moved their protocols to accept the current science — and who don’t let the possession of a “card” define competency or currency in resuscitation science.[1]


The whole purpose of merit badge cards is to relieve the medical director of responsibility for oversight of competence.

How was I to know the medic was incompetent? He had a license to kill merit badge to kill and that is all anybody can require.

I wash my hands of any responsibility for actual oversight.

Plausible deniability is the reason for merit badge requirements.

We are trying to hide from responsibility by adhering to low standards.


[1] Controversial post for the week
October 9, 2013
The Ambulance Chaser


Why Did We Remove Atropine From ACLS? Part II


Continuing from Part I.

The AHA (American Heart Association) stopped recommendeding use of atropine for the treatment of PEA (Pulseless Electrical Activity) or asystole in the 2010 ACLS (Advanced Cardiac Life Support) guidelines.

There is not much information given, but that little bit of information just makes it more clear that we never had a good reason for making atropine a standard part of ACLS.

One sentence at a time, look at the reasoning –

Interventions Not Recommended for Routine Use During Cardiac Arrest

Atropine sulfate reverses cholinergic-mediated decreases in heart rate and atrioventricular nodal conduction.[1]


There is a hypothetical justification for atropine based on physiology/pathophysiology.

There has been a hypothetical justification for every treatment found to be harmful. That hypothetical justification did not protect patients from real harm.

No prospective controlled clinical trials have examined the use of atropine in asystole or bradycardic PEA cardiac arrest.[2]


Why was a treatment that had never been demonstrated to improve outcomes recommended and the standard of care?

Without evidence of improved outcomes, should any treatment be used outside of controlled trials?

Lower-level clinical studies provide conflicting evidence of the benefit of routine use of atropine in cardiac arrest.34,295,–,304 [1]


To translate – Useless information is . . . useless.

There is no evidence that atropine has detrimental effects during bradycardic or asystolic cardiac arrest.[1]


Is atropine the alternative medicine of cardiac arrest?

This sentence contradicts the evidence review that led to the removal of atropine from the guidelines.

Here is a listing of the evidence that opposes the use of atropine for cardiac arrest.

Click on image to make it larger.[2]

While the evidence of harm is not great, the evidence of benefit is not great, either.

Evidence of worse outcomes from cardiac arrest is evidence of harm.

There are four studies – three that show a negative correlation with atropine and survival to discharge.

no evidence that atropine has detrimental effects?

The positive studies are also just showing correlation. Poor studies mean poor information. Why were we giving atropine based on poor information?

We were giving atropine based on wishful thinking.

Available evidence suggests that routine use of atropine during PEA or asystole is unlikely to have a therapeutic benefit (Class IIb, LOE B).[1]


We should not include treatments that do not have evidence of therapeutic benefit.

For this reason atropine has been removed from the cardiac arrest algorithm.[1]


For this reason, atropine should never have been included in the cardiac arrest algorithms.

For this reason, all treatments that do not have evidence of therapeutic benefit should have an expiration date.

If no evidence is provided, the treatment is removed from the guidelines.

This would apply to ventilations, epinephrine (Adrenaline), vasopressin (Pitressin), norepinephrine (Levophed), and phenylephrine (Neo-Synephrine) in cardiac arrest.

This would also apply to amiodarone (Cordarone), lidocaine (Xylocaine), and Magnesium in VF (Ventricular Fibrillation) cardiac arrest.

What does that leave us with?

Compressions in cardiac arrest.

Defibrillation in VF cardiac arrest.

Therapeutic hypothermia after resuscitation.

In Part III I will look at the most positive study supporting the use of atropine for cardiac arrest.


[1] Atropine
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8.2: Management of Cardiac Arrest
Interventions Not Recommended for Routine Use During Cardiac Arrest
Free Full Text from Circulation.

[2] Atropine for cardiac arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Appendix: Evidence-Based Worksheets
Part 8 ALS
Swee Han Lim
Evidence-Based Worksheet Download in PDF format.

That link is no longer available, but the overall page of evidence-based worksheets is available in PDF format here.


Comment on Why Did We Remove Atropine From ACLS? Part I


In the comments to Why Did We Remove Atropine From ACLS? Part I is this from BLS in Wichita

Another important question…why are we even attempting resuscitation on many of the patients we encounter in sudden cardiac arrest. Many of these lives are not savable, yet it’s all hands on deck for a wasted heroic effort. We dump tons of resources in to a futile effort.


We do.

The AHA (American Heart Association) continues to try to come up with better answers for these problems, but they are often not easy to solve.

Shouldn’t we be applying our resources where they are needed most, rather than on an octogenarian with multiple medical problems and stage 4 cancer?


That raises some important questions.

If ACLS is for hearts too good to die, then why apply it to people who are dying from other causes?

It now seems possible that with an adequate program of prevention, continuous monitoring and with a prompt aggressive approach to the prevention and ablation of serious cardiac arrhythmias, fewer acute coronary patients will be dead with “hearts too good to die.”[1]



This is from 1967, so there is mythology that has been discarded, such as the need to give atropine with morphine to avoid arrhythmia.

However, they do describe their rate of successful defibrillation to some sort of improved outcome.

What is the improved outcome?

ROSC (Return Of Spontaneous Circulation)?

Survival to non-arrhythmic death?

Survival to discharge?

We do not know.


13% survival to discharge would be good for 1967, especially since the expected alternative would be death, but is it 13% survival to discharge?

One reason we try to resuscitate far more people than just the hearts too good to die is that arrhythmia is not the only reversible cause of cardiac arrest.

Another reason is that we refuse to differentiate between quantity of life and quality of life.

We also are not good at recognizing our limitations.

What about a DNR (Do Not Resuscitate) order?

Some patients do not have the kind of DNR that EMS is permitted to follow, so we are required to call medical command for orders to follow a legal document that says don’t do all of the things that we do.

We can be a very destructive force once we are set in motion, because we are required to do things that we would be prohibited from doing to other people outside of EMS – and we are not good at recognizing this.

Some EMS providers will decide that it is more important that they attempt resuscitation, than respect the legally valid decision of the patient – and EMS rules do not discourage this.

The patient knows why he does not want to be resuscitated, but some of us only respect a patient when the patient makes the decision we want him to make.

A couple of EMTs from the local ambulance company responded to a call I was dispatched on for difficulty breathing. The patient was about 50 years old and had a DNR. The DNR did not affect care on that call, but both EMTs (older than the patient) stated that they would refuse to honor the DNR, because He is too young to have a DNR.

We have people who think they are helping, but are making things worse.

These are people who should not be in EMS.

EMS is not about taking care of the patient not taking care of our egos.

If the patient’s wishes do not match our desires, we need to grow up and provide patient care.

Resuscitating an octogenarian is something that is not bad. An 80 year old male is expected to live for 8 more years, while an 80 year old female is expected to live for 10 more years.

Quality of life is important. Having stage 4 cancer and being resuscitated to be able to have another painful death is not good patient care, unless that is what the patient wants.

We need to pay attention to quality of life and patients’ wishes and stop trying to force patients to live according to our prejudices.


[1] Hearts too good to die–problems in acute myocardial infarction.
Johnson JB, Cross EB.
J Natl Med Assoc. 1967 Jan;59(1):1-6. No abstract available.
PMID: 6038580 [PubMed – indexed for MEDLINE]

Free Full Text from PubMed Central.


Why Did We Remove Atropine From ACLS? Part I


As of 2010, atropine is gone from the ACLS (Advanced Cardiac Life Support) treatment guidelines and nobody seems to be upset. We never had good evidence to support treatment of dead people with atropine, but we practiced this witchcraft because we chose optimism over evidence.

Some people claim that the constant changes to ACLS are evidence that evidence does not work.

That is not true. We ignored the lack of valid evidence. We chose to be ignorant.

We keep changing guidelines as we keep learning more. We should require valid evidence before adding treatments to guidelines, but too many of us are overly optimistic about treatments that are not supported by valid evidence. We believe that this time will be different. After we study treatments, we generally find out that we have been harming more patients than we have been helping.

Atropine is one example.

Look at all of this evidence of benefit.

Click on images to make them larger.[1]

What do the LOE (Level Of Evidence) and Good, Fair, and Poor categories mean?

The LOEs were subdivided into three major categories, depending on the type of question being asked: intervention, diagnosis, or prognosis. The quality of evidence categories were reduced from five categories in 2005 to three (good, fair, poor) in 2010.[2]


There is no further explanation of how Good, Fair, and Poor were to be decided, but there is an explanation of what the LOEs mean.

Level A is the evidence least likely to be misleading –


Level B is evidence that is much less likely to provide an accurate representation of the true effect of the intervention, because there are many more variables that are not controlled for –


Level C is the lowest evidence possible and even includes a category that is not really evidence – Expert Opinion


Expert Opinion is lower than the lowest of the low evidence.

In the chart Evidence Supporting Clinical Question, there is no column for expert opinion, because there is no good reason to include expert opinion in the analysis of evidence.

But what about the evidence that is there supporting the use of atropine?

Why is everything poor evidence?

Why isn’t there anything better than LOE 3: Studies using retrospective controls?

If the most positive study was back in 1984, and it was only LOE 3, why did we only remove atropine from the cardiac arrest guidelines in 2010?

The supporting evidence is not the only evidence, but that is not a good answer to my question.

The weak evidence in support of atropine in cardiac arrest is more than matched by stronger evidence that atropine does nothing useful –


There is also weak evidence that atropine is harmful –



How did atropine ever make it into the ACLS guidelines based on such poor evidence?

To be continued in Part II and Part III.


[1] Atropine for cardiac arrest
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Appendix: Evidence-Based Worksheets
Part 8 ALS
Swee Han Lim
Evidence-Based Worksheet Download in PDF format.

That link is no longer available, but the overall page of evidence-based worksheets is available in PDF format here.

[2] Classification of Evidence
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 2: Evidence Evaluation and Management of Potential or Perceived Conflicts of Interest
Evidence Evaluation Process
Free Full Text from Circulation.


Up to a Maximum of X Times vs. Titration

Over at Ridin’ the Bus, Gertrude was writing Who’s teaching the teachers? Well, my answer is that the teaching jobs are often as political as the desirable EMS jobs. Squad Y is a bunch of people friendly with So-and-So. Squad B is a bunch of people friendly with Whojamacallit. Whether these are 911 jobs, critical care jobs, flight medic/nurse jobs, or anything else does not matter. There is more of an old boy network involved than a critical examination of the qualifications of a job candidate. Teaching is no different.

The current teachers are not necessarily those who excelled in medic school, or EMT school, when they attended. They might not have learned things all that well, when they were in school. The instructor may have modified his understanding since then, but that does not mean that it was for any medical reason. A lot of what is taught is pure speculation.

I described this in several posts A, B, C, D, and E. I reference it in several others. We are poorly educated. The educators often do not know what they are doing well enough to be teaching it.

An excellent example of this is cardioversion. I have never seen anyone else do a good job of teaching cardioversion. That does not mean that it does not happen, but it is not encouraging that I do not see it taught well. ACLS (Advanced Cardiac Life Support) encourages us to just review the material, since the students are already supposed to be familiar with everything. How many nurses going to their first ACLS class have any experience with cardioversion? This is not something that you learn to do well from a book or a blog. You learn it by using the paddles, turning on the synchronizer, and delivering shocks to a mannequin or to a patient. Too many people learn, during their first cardioversion, that they never really understood cardioversion.

Anyway, the topic of Gertrude’s post was the rules that are taught to us. Her example is when a student asked her for the maximum number of times a patient can be suctioned.

Think about this.

Why do we suction patients?

We suction them because there is something in the airway that may interfere with ventilation. It may be a potential obstruction. It may be a partial obstruction. It may be a complete obstruction.

As long as we do what we can to maintain oxygenation, there is no maximum. For the complete obstruction, there is no reason to pause and ventilate in between suction attempts, or to limit the length of suctioning, unless there is the possibility that you have cleared, or partially cleared, the obstruction.

One of the other instructors had given them a number. What is a good number for this? 3? 5? 23? The patients weight in kilograms, divided by their SpO2 percent, multiplied by the number of synapses actually transmitting information in that instructor’s brain?

How about until the portable battery runs out? But remember there are other ways of creating suction – a large syringe, a bulb syringe from the OB kit, scooping things out of the airway, gravity, a vacuum cleaner in the residence. Who really cares how you do it, if you are able to provide the airway the patient needs?

Why do we feel the need to have a number? A limit on what we can do?

People like externally imposed limits. The idea of being responsible for making intelligent decisions is something that many people flee from.

“Responsibility? Just tell me what I have to do to avoid getting in trouble.”

“As long as I follow the protocol, I won’t get in trouble.”

Of course, if the protocol does not apply to your patient, or if you follow the wrong protocol (because you ignored assessment in favor of memorization of protocols) you might kill your patient in your devotion to keeping out of trouble.

Maximum of 3 NTG (NiTroGlycerin, overseas GTN – GlycerylTriNitrate).


Most likely because the AHA wants you to switch the patient to IV NTG as soon as possible. Not exactly common in the prehospital setting, but a very good idea. NTG is a drug that needs to be titrated. A maximum number prevents titration, so people teaching these maximums should not be teaching. Titration is adjusting the dose based on the response of the patient. Almost all EMS drugs need to be titrated.

Does a response mean that you stop? No, but you take that information into consideration in your continuing doses. Sometimes it will mean to stop. NTG + Syncope is more than a subtle hint to stop NTG. After blood pressure returns, then you may resume cautiously (perhaps after running a liter into the patient) or you may decide not to give any more, but initially your response should be to stop.

Atropine is not a titration drug. Fast push, a minimum adult dose of 0.5 mg and a maximum dose of 0.03 mg/kg if stable, 0.04 mg/kg if unstable. With atropine, you may get the opposite result of what you want, if you give it slowly or if you do not give enough. Another non-titration drug is adenosine. Also fast push. Maximum of 3 doses – 6 mg, 12 mg, and another dose of 12 mg. Glucagon is another drug not generally titrated (many places do not even carry more than one dose).

Some titration drugs:

Oxygen – titrate to adequate oxygenation.

Dextrose 50% in Water – titrate to adequate saccharinity.

Dopamine and dobutamine are given as drips, the dosage formula is for calculating a starting dose and for understanding the maximum dose rate, which does not mean that you stop, only that you stop increasing the dose rate.

NTG – I have given over 50 sprays (over 20 mg) to a single CHF patient on one call and the blood pressure never dropped below 200 mm/hg systolic. Maximum of 3? Not a chance.

Albuterol (Salbutamol overseas)- if the patient is not able to breathe adequately, we continue giving albuterol, but we add other beta 2 agonists, maybe some magnesium and methylprednisolone. There are some who will even tell you that you may not give albuterol to a tachycardic or hypertensive patient, since it is not completely selective for beta 2 and might make things worse. Yes, it will stimulate the heart to work harder, but if it opens the airways, the pressure and heart rate will come down in spite of that stimulus. If it doesn’t open the airways, the side effects are not the patient’s primary concern, not even a secondary concern.

Fentanyl/dilaudid/morphine – no minimum dose and no maximum dose. Only the response to treatment matters. No maximum of 6 mg, or 10 mg, or 20 mg, or even 100 mg of morphine (about 60 mcg/100 mcg/200 mcg/1 mg for fentanyl; 0.75 mg/1.25 mg/2.5 mg/12.5 mg for dilaudid). Anyone who tells you otherwise is a liar and/or incompetent.

Midazolam/lorazepam/diazepam – no minimum dose and no maximum dose. Only the response to treatment matters. No maximum of 5 mg, or 10 mg, or 20 mg, or even 100 mg of midazolam . . . .

Diltiazem is a slow push medication that has standard doses (0.25 mg/kg for the initial dose and 0.35 mg/kg for a repeat). If you are giving it slowly it isn’t just to minimize the side effects, but also to observe for side effects that would discourage you from continuing with the dose. Diltiazem is often given to little old people, who may not give much warning before dropping their blood pressure significantly. I like to keep them sitting up and talking to me while I slowly (over 5 minutes, not the recommended 2 minutes) push the diltiazem. If they are sitting up, the part of the body most likely to show signs of decreased perfusion is the brain – sooner than a repeat blood pressure, sooner than skin sign changes. If the behavior changes in any way, I stop and I do not give any more until after I have satisfied myself that this is not a sign of an adverse reaction. I can always give more later, but most likely it is an adverse reaction.

Naloxone – no minimum dose and no maximum dose. I like to give 20 mcg to 40 mcg at a time. Response is what tells me when to stop.

These are just some of the drugs that are only appropriately given when titrated.


Dispatch would have told us if it were something serious.

The 911 crew walk to the house with just a little “first in” bag.


It’s just a syncope call.

No monitor. No thinking. No understanding of patient care. No anticipation of what might be needed.


Because that is the way things are done in that area.


Certainly Deborah Peel can wait until they go back to the ambulance, get the stretcher, bring the stretcher to Deborah Peel. They were expecting Deborah Peel to walk. He’s not known for being that cooperative. Then they wheel Deborah Peel out to the ambulance, where the heart monitor is waiting, as yet unused.

Now that they are in the ambulance, the assessment and treatment can begin.

This is not much different from the medical command approach of “Just transport.”

Anything that happens outside of the Emergency Department doesn’t count.

Of course EMS has translated that to – Anything that happens outside of the ambulance doesn’t count.

The basic EMT is expecting that the medic will come up with a way to make Deborah Peel appear stable – stable enough to go to the hospital without any ALS (Advanced Life Support) care. In other words, the medic does not have to do anything, except drive.

So, they take a blood pressure, but there are problems obtaining the number. They can only get occasional beats. When you are letting the pressure out of the cuff quickly, there can be a bit of a “inaccuracy,” especially if the beats are not cooperating by being close together.

Well, they know that the number can’t be right because that would be really bad.

Why don’t we hook up the monitor? Oh, yeah, good idea. Then we can find out what his heart rate is. The monitor is the keeper of the heart rate on ALS calls, just as the pulse oximeter is the keeper of the heart rate on BLS (Basic Life Support) calls. For some reason the pulse oximeter malfunctioned on Deborah Peel, even though they spent a lot of time trying to troubleshoot it. The best they could get was a sat in the low 80s and a heart rate in the upper 20s.

Now, you are probably already experiencing more than a little frustration reading this. I was watching this as we were returning from the hospital to our station. We had heard the call dispatched and I asked my partner why the crew was coming out of the house with a syncope patient, but without the monitor. The response – “None of the medics do that. You and Jeff are the only ones who bring monitors in on this kind of call.”

Great Googly Moogly, I done died and went the wrong way.

As we are wandering over to lend a hand, which my partner says is a bad idea (not the first time I’ve heard that), we overhear the blood pressure confusion. They are hooking up the monitor and have a nice wide complex bradycardia* on the monitor. The medic automatically grabs the IV kit and tells his partner to get the atropine out.

Since I am just helping, I put an oxygen mask on Deborah Peel. I even turn the oxygen on. I ask about blood sugar and they actually did that inside. The blood sugar is in the normal range.

I suggest, in my helpfulness, that pacing might be a good idea, since Deborah Peel is clearly unstable. As in unconscious, hypotensive, and bradycardic. That atropine is not helpful for ventricular bradycardias. But, they don’t approach ACLS that way. Pacing is something they do not use. Why? I do not recall the response to that question, maybe I never got a response, maybe I was just doing a better job of keeping my mouth shut at that point – to avoid letting out the screaming that is going on in my mind.

The hospital is two minutes away, otherwise we would not have been driving by this call. Do they start driving? No, the EMT has to help the medic with the IV start, spike the bag, cut the tape, hand the tape to the medic, . . . .

The atropine does not make things worse. Then they drive lights and sirens to the hospital.

Everything is already done, as far as the protocol is concerned. Chart review on this should earn the medic brownie points for being so diligent in care. The medical director can rest easy. This officer is one of the good ones, making sure that the others are kept in line. Passing on the right way to take care of patients.

But the chart and reality do not have anything to do with each other. Do they?

For a different perspective, what if this had been something that fell into the significant trauma category?

Well, we would drive to the hospital and meet the helicopter there at the landing pad.

How far of a drive is it to the trauma center?

15 to 30 minutes.

So, to save a few minutes of drive time, you fly the patient?

We have to. We can’t deprive our service area of our excellent patient care. If we aren’t here, mutual aid from the next town over might have to come in and treat our patients.

This reasoning almost makes sense. These guys have seen the neighboring EMS and don’t trust those guys.

Those guys are dangerous!

Of course, the only difference between them is the uniforms. When not working their full time job as these guys, most of these guys work part time as those guys, many of those guys work part time as these guys, but some of those guys work part time as other those guys. This keeps the overtime down.

These guys and those guys probably even pass the National Registry of EMTs paramedic test without any problems.

If you don’t purchase the program on the way into the ball park, you aren’t going to know who the players are.

* Bradycardia means s l o w. In this case to the point of not circulating enough blood to the brain to remain conscious. Wide complex means that even the electricity in the heart is moving very slowly. The heart is slow and the electricity is not connecting efficiently. This may mean that the lower part of the heart is causing the heart to beat. Normally a group of heart cells in the top of the heart (the sinus node) are in charge of causing the heart to beat, if they fail, then farther down the conduction system, where the upper part and the lower part of the heart meet, there is a back up to the sinus node (the AV junction), but even that is not working for Deborah Peel.

Not really a big problem. He just needs a ________.

Even those of you not big on cardiology can probably figure out the word that goes in there. The word is pacemaker. Deborah Peel will receive one in the hospital.

My other helicopter misuse posts are:

Interfactility Helicopter EMS

Helicopters and Airways

Helicopter EMS – The Starbucks Effect.

Safety über alles!