A Baltimore mother searches for answers as to why her son died after being restrained and sedated by doctors.
Trea Ellinger, 29, left a Baltimore drug rehab facility last July, assuring his worried mother that he was OK. He had his medications and was planning to meet up with his girlfriend.
But the next afternoon he was dead. Not from the violence his mother feared, but because he didn’t survive an encounter with emergency workers in downtown Baltimore, who claimed to have found him in the middle of the street, trying to commit suicide and “fighting with people.”
Ellinger, 29, died after being sedated and coerced.
According to investigators and experts, police and emergency services repeatedly indicated that it is dangerous to lie on your stomach, but emergency services failed to respond quickly when the handcuffed Ellinger turned onto his stomach and remained there for several minutes.
Trea Ellinger, 29, died after being sedated and coerced by police and doctors in Baltimore last July
Lori Ellinger holds a candle with a photo of her son, Trea Ellinger
His death is one of many similar cases that have quietly spread across the country over the past 15 years as administering tranquilizers to those detained by police has become a common practice.
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 truly believe they killed my son with that shot,” she said. “He should not have been dead at 29.”
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 oversees the city’s medics, provided copies of its policies on the use of sedatives, physical restraint and other related topics.
However, the agency would not comment on the circumstances surrounding Ellinger’s death, citing potential future litigation.
None of the aid workers involved have been charged and Ellinger’s family has not filed a lawsuit.
Medics were first on the scene, but when police arrived, they had difficulty handcuffing Ellinger so doctors could sedate and treat him.
Ellinger, 29, of Maryland, was knocked unconscious for a time after being restrained by officers and placed on an ambulance stretcher
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 shows officers handcuffing Ellinger at the request of doctors.
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, he’s fine,” one of the doctors says.
Ellinger was initially turned back onto his side, but his continued movements caused him to end up on his stomach as rescuers secured the stretcher’s straps, the report said.
In the ambulance, a medic began checking his vital signs while another sat by his head. He remained facedown, sometimes struggling against the straps of the stretcher, the report said.
Four minutes later, the doctors discussed the possibility of moving Ellinger, but they did not do so immediately.
After another minute, Ellinger was moving “only slightly,” the report said.
In the ambulance, strapped to the stretcher, Ellinger continued to struggle with the doctors and became unresponsive a few minutes later.
Finally, a doctor loosened the straps and helped Ellinger roll onto his side. He noticed that his lips were blue.
The same doctor told his colleague that he could administer Narcan, a drug used to treat opioid overdose.
According to the report, Ellinger was released from his handcuffs and placed on his back as doctors began performing chest compressions.
He regained a heartbeat and was taken to 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 prison deaths.
In this case, the investigators specifically stated that their task was only to investigate the actions of the police officers, not those of the doctors or other emergency responders.
According to Eric Jaeger, an emergency medicine professor in New Hampshire who is not involved in the case, the most obvious problem was that doctors left Ellinger on the floor for several minutes, possibly impeding his breathing.
He says he shows the bodycam footage to his students as an example of what can go wrong when a patient’s airway is not 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.
Police removed the handcuffs to perform CPR, but Ellinger later died in hospital
Photos by Trea Ellinger are on display at Lori Ellinger’s home in Glen Burnie, Maryland
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 “should place the patient in a supine (face-up) position as soon as possible.” Another policy states that a restrained patient “should be placed face-up or on the side if possible.”
Firefighters declined to answer questions about the case, including whether the fire department is conducting an internal investigation.
The union representing firefighters and emergency workers also declined to comment, and the mayor’s office did not respond to recent questions about the matter.
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.”
Lori Ellinger wears a necklace in the shape of a guitar, which symbolizes the passion her late son Trea Ellinger had for music
Ellinger died in July 2023. 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 cope with the untimely death of her only child.
She wears a necklace in the shape of a guitar, which symbolizes Trea’s passion for music.
She flips 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 problems with substance abuse, he spent much of his twenties traveling the country as a carnival ride, and he loved the job.
In the months before his death, he tried to stay on track, using 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 some groceries the day before he died.
She said he seemed in good spirits, but that 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 facility 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 cries as she watches the videos and reads the report, because she feels her son’s grief.
It was clear he was in crisis, but it wasn’t until hours later that she received a call from a nurse telling her he had already died.
“I love him and miss him,” she said. “We had a lot of good years — but not enough.”