BALTIMORE — When Trea Ellinger left a drug rehab facility in Baltimore last summer, he assured his worried mother that everything was fine. He had his medications and planned to meet up with his girlfriend.
The next afternoon he was dead, not from the violence his mother feared, but because he had not survived an encounter with emergency workers in downtown Baltimore.
Ellinger, 29, died after being sedated and restrained. Despite repeated warnings from police and medics at the scene acknowledging the dangers of lying face down on one’s stomach, first responders failed to act quickly when the handcuffed Ellinger rolled onto his stomach and remained there for several minutes, investigators and experts said.
His death adds to the list of similar cases. recent research under the direction of The Associated Press, it was discovered that the practice of giving sedatives for people arrested by the police has quietly spread across the country over the past 15 years. The strategy, intended to reduce violence and save lives, has led to a number of preventable deaths.
In Ellinger’s case, the autopsy determined he died from an overdose of antidepressants and methadone, which is often prescribed to curb opioid cravings. The findings did not indicate whether other factors may have contributed to his death.
His mother, Lori Ellinger, questions the autopsy findings and wants to know why emergency responders decided to use an injectable sedative.
“I believe they killed my son with that shot,” she said. “He should not have been dead at 29 years old.”
According to independent experts, Trea Ellinger may have died from the combined effects of the anesthesia and the prone position, which can block a person’s airways.
The Baltimore City Fire Department, which employs the city’s medics, provided copies of its policies regarding the use of sedatives, physical restraints and other related topics. But the agency declined to comment on the circumstances surrounding Ellinger’s death, citing the possibility of future litigation.
None of the aid workers involved have been charged and Ellinger’s family has not filed a lawsuit.
According to an investigative report released in May by the Maryland Attorney General’s Office, a 911 caller reported seeing a man lying in the middle of a street in downtown Baltimore, speaking unintelligibly and acting aggressive and tense.
Police bodycam footage of the encounter shows officers handcuffing Ellinger at the request of medics. Officers placed him on his side until he was given an injection of midazolam, then lifted him onto a stretcher.
“As long as he’s not face down, that would be great,” one of the doctors said.
Ellinger was initially turned back onto his side, but his continued swaying caused him to lie on his stomach as rescuers tightened the gurney straps, the report said. In the ambulance, a medic began checking his vital signs while another sat by his head. He remained facedown and at times struggled against the gurney straps, the report said.
Four minutes later, the medics discussed moving Ellinger, but they took no immediate action. After another minute, Ellinger was “still moving only slightly,” the report said. Eventually, a medic released the restraints and helped Ellinger roll onto his side, noting that his lips were blue. The same medic told his colleague that he could administer Narcan, a medication used to treat opioid overdose.
Ellinger was released from the handcuffs and placed on his back while medics performed chest compressions, the report said. He regained a pulse and was taken to the hospital, where he later died.
The report was prepared under a relatively new state law that requires the Maryland Attorney General’s Office to investigate all deaths in custody. In this case, investigators specifically noted that they were charged only with investigating the actions of the police officers, not the medics or other first responders.
Eric Jaeger, an emergency medicine instructor in New Hampshire who is not connected to the case, said the most obvious problem was that the medics left Ellinger on the floor for several minutes, potentially impairing his ability to breathe. He said he shows the bodycam footage to his students as an example of what can go wrong when a patient’s airway isn’t prioritized during sedation.
“I think Trea Ellinger would be alive today if he had been placed face up on the stretcher,” Jaeger told the AP.
He also questioned the original decision to sedate Ellinger, saying doctors must be especially careful when administering such drugs because of the risks they entail.
When treating an agitated patient, fire department policy dictates that physicians “place the patient in a supine (face-up) position as quickly as possible.” Another policy says that a restrained patient “should be placed face-up or on the side if possible.”
Fire officials declined to answer questions about the case, including whether the agency is conducting an internal investigation. The union representing firefighters and paramedics also declined to comment, and the mayor’s office did not respond to recent questions about the case.
It appears that the decision to sedate Ellinger with midazolam was in accordance with department policy.
Gail Van Norman, a professor emeritus of anesthesiology at the University of Washington, said the sedative may have suppressed his breathing and relaxed the muscles of his upper airway, making him more vulnerable to cardiac arrest.
“The medics made some medical errors,” she said. “But this was a fast-moving situation where the unexpected happened. I don’t envy them the decisions they had to make.”
Ellinger died last July. In April, Baltimore prosecutors announced their decision not to file charges. The investigation report was released the following month.
Meanwhile, Lori Ellinger is still trying to come to terms with the untimely death of her only child. She wears a guitar necklace that symbolizes Trea’s passion for music. She scrolls through old photos on her phone, reminiscing about his childhood.
Trea Ellinger grew up in rural northeastern Maryland and worked for a concrete company after high school. Despite his struggles with substance abuse, he spent much of his 20s traveling the country with a traveling carnival, a job he loved. In the months before his death, he tried to stay on track, taking methadone to curb his opioid cravings.
According to his mother, he had previously been diagnosed with mental health problems, including bipolar disorder and schizophrenia.
Lori Ellinger visited her son at his rehabilitation center and brought him groceries the day before he died. She said he seemed in good spirits. But a few hours later, he called and said another resident had stabbed him in the shoulder during an argument. His injuries were not serious, but the center asked him to leave, she said.
She believes he slept on the street that night. The next afternoon, he was seen stumbling in downtown Baltimore, falling repeatedly and acting disoriented, the investigative report said.
Lori Ellinger watches the videos and reads the report and her heart breaks for her son. It’s clear he was in some kind of crisis, but she didn’t get a call until hours later when a nurse told her he was already dead.
“I love him and miss him,” she said. “We had a lot of good years — but not enough.”