As an ex 135 air ambulance pilot, I can back up EVERYTHING posted! I was based on an indian reservation and 95% of our patients were well north of 200 lbs. We'd always have the ambulance driver help us load the patients into the 414 and that was still a struggle. I'd always fly within 50 lbs of max gross weight
We'd pick up at really small airports (3500 ft long) in the summer time and DAs were pushing 10,000 ft so I was just getting past 80 kts and looking down at the numbers as I rotated. Talk about pucker factor.
The aircraft were well maintained but old. the 414 hasn't been built in a few years so all of ours were 1980s models and had seen a number of flight hours.
I always filed but the option was ours to fly VFR if we chose. I found it easier to file and have priority handling from controllers during the hour of terror that your patient is fighting to stay alive.
I wrote an essay about one of my flights. PM me if anyone is interested in reading it. Pretty shocking story.
Good luck in your decision.. I'm headed back to the airline but miss my days of flying sick folks around.
-G