I'm looking at the Delaware systems. Seems like it works well, and I haven't heard any real negatives.
I oriented a medic who worked for one of the DE ALS services and he had some gripes about management, but I hear those sorts of complaints from almost every place. DE has a state wide ALS response time standard (8:00/90), so the lower two counties, which are mostly rural, have more medic units than necessary, in my opinion. (Stupidly, the standard isn't as strict for BLS.) So, the skill concentration thing isn't going to apply as much. I talked with a medic from one of the lower two counties and he said that they almost never triage to BLS and used an example of BLS requesting medics because they got a SpO2 reading of 80%; the medics discovered that it was malfunctioning, but rode the patient in anyways. Another downside I've heard of the lower two counties is that because medics can split, it's possible to end up at hospitals that are far apart and having to wait hours to meet back up with your partner. But, I don't know how common that is (to me it's not a big deal anyways).
Overall, I think DE has a pretty good system. Strong QA/QI, good medical oversight, good protocols, research, etc. New Castle County has a utstein survival rate over 30%.. The statewide ETI success rate is around 92%. It's all county based and as far as I know, they have all have decent career ladders, benefits, and retirement packages. Also, if you like to fly, the medics in the lower 2 counties will accompany the patient for the flight if it is the state police helicopter responding.
The state website has a lot of great info. Since I don't work there, take what I say with a grain of salt as I could be wrong.
If you go to connect.jems.com, there is a NCC medic by the name of Bob Sullivan that regularly posts, I'm imagine he'd be willing to answer questions you may have.
