MD, thanks for your comments. I can certainly agree.
Dr. Bell was not the ER doc. The ER doc settled. Dr. Bell was the admitting physician, who apparently did not see the patient. I don't understand how the patient got discharged without being seen by the admitting physician.
I agree that it looks like the dx of CVA was missed. The article doesn't describe whether any treatable etiology was discovered.
You wrote, "surely you concede..." I didn't take any position one way or the other. But you are right, a simple referral when you don't know what's going on is certainly appropriate.
In the composite case I described, the ER doc did make a referral, to the ophthalmologist, where further testing did make the dx. I actually think the referral to the ophthalmologist made the dx more quickly that admission would have, as the hospital didn't have a neurologist and it is not likely that the local MD would have made the dx.
You talked about transfer to a stroke center. My experience in small to large community hospital ER's and as a hospitalist is that the referral hospitals, whether a stroke center or just a larger hospital with a full-time neurologist, wouldn't take the patient in transfer.
I recently had an inpatient woman, relatively young, with right sided hemiplegia and expressive aphasia and a very large stroke. Likely related to methamphetamine use. Anyway, despite the fact that her stroke enlarged and became more dense on CT, and that her symptoms were worsening, no one would accept her in transfer. I was advised that we could do everything for her that they could as the presentation wasn't acute.
It is unlikely that either of the docs I discussed would have been able to effect a transfer.