I run in a hospital-based EMS system. We have a station in the city, and we also have a unit based in a VFD in a rural town about 15 miles outside of the city limits. The coverage area of the rural unit is about twice the size of the city, and covers four towns and a wildlife refuge. Granted, there are more calls in the city, but they are rotated between three units during the day, and two at night. The rural unit handles all of the calls in their coverage area, sometimes running more calls than the city units combined in a regular shift.
Since we are all based out of the hospital, there is no difference in protocols, rules, regulations, etc... between the two, plus the EMT's from the rural unit regularly run shifts in the city during their time off.
I agree that the transport times may be longer in the rural areas, but there is always ALS assist available, and the EMT's have the smarts to use the skills they have obtained both in the city, and in the sticks. I would gladly put our rural EMT's up against the city folks any day.
G.