A Baltimore mother is seeking answers about her son’s death after doctors restrained and sedated him.
Trea Ellinger, 29, had checked out of a drug rehab center in Baltimore last July and assured his anxious mother that everything was fine. He had his medication and planned to meet up with his girlfriend.
But by the next afternoon, he was dead — not from the violence his mother feared he might face, but because he did not survive an encounter with first responders in downtown Baltimore who claim to have found him in the middle of the street attempting suicide and “fighting with people.”
Ellinger, 29, died after being sedated and restrained.
Despite repeated comments from police and medics at the scene acknowledging the dangers of lying face down in the prone position, first responders failed to act urgently when a handcuffed Ellinger rolled onto his stomach and remained there for several minutes, according to investigators and experts.
Trea Ellinger, 29, died after being sedated and restrained by police and medics in Baltimore last July.
Lori Ellinger holds a candle with a photo of her son, Trea Ellinger
Her death adds to a list of similar cases as the practice of administering sedatives to people in police custody has quietly spread across the country over the past 15 years.
The strategy, which was intended to reduce violence and save lives, has resulted in some preventable deaths.
In Ellinger’s case, an autopsy determined she died from an overdose of an antidepressant and methadone, which is commonly prescribed to curb opioid cravings. The findings did not indicate whether other factors might have contributed to her death.
His mother, Lori Ellinger, questions the autopsy findings and wants to know why paramedics decided to use an injectable sedative.
“I think my son was killed with that shot,” he said. “He shouldn’t be dead at 29.”
Independent experts say Trea Ellinger may have died from the combined effects of being sedated and lying face down, which can obstruct a person’s airway.
The Baltimore City Fire Department, which employs the city’s medics, provided copies of its policies on the use of sedatives, physical restraints and other related issues.
But the agency declined to comment on the circumstances surrounding Ellinger’s death, citing the possibility of future litigation.
None of the first responders 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 medics could sedate and treat him.
Ellinger, 29, of Maryland, became unconscious some 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 that a man was lying in the middle of a downtown Baltimore street, speaking in an incomprehensible manner and acting combative and distressed.
Police body camera footage of the encounter shows officers handcuffing Ellinger at the request of medics.
Officers placed him on his side until they injected him with midazolam, then lifted him onto a stretcher.
“As long as he’s not face down, that would be great,” one of the doctors says.
Ellinger was initially placed on his side again, but his continued movements caused him to fall face down as rescuers attached the stretcher straps, the report said.
Inside the ambulance, one doctor began checking his vital signs while another sat at his head. The man remained face down, at times struggling against the stretcher straps, the report said.
Four minutes later, doctors discussed the possibility of repositioning Ellinger, but did not act immediately.
After another minute passed, Ellinger “was moving only slightly,” the report says.
Inside the ambulance, while strapped to a stretcher, Ellinger continued to struggle with medics and became unresponsive minutes later.
Finally, a doctor released the straps and helped Ellinger turn onto his side, noticing that his lips were blue.
The same doctor told his colleague that he could give him Narcan, a drug used to reverse opioid overdoses.
Ellinger’s handcuffs were removed and he was placed on his back as medics began chest compressions, the report said.
He regained his pulse 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 in-custody deaths.
In this case, investigators specifically noted that they were only tasked with investigating the actions of police officers, not those of doctors or other first responders.
Eric Jaeger, an emergency medical services educator in New Hampshire who has no connection to the case, said the most obvious problem was that medics left Ellinger face down for several minutes, potentially hampering his ability to breathe.
He said he shows body camera 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 on the gurney face up,” Jaeger told AP.
Police removed his handcuffs to perform CPR, but Ellinger later died at the hospital.
Photographs of Trea Ellinger can be seen on display at Lori Ellinger’s home in Glen Burnie, Maryland.
He also questioned the initial decision to sedate Ellinger, saying doctors should be especially discerning about when to administer such drugs because of the risks they pose.
When dealing with an agitated patient, fire department policy instructs medics to “place the patient in the supine (face up) position as soon as possible.” Another policy says an immobilized patient should be placed “on their back or side, if possible.”
Fire officials declined to answer questions about the case, including whether the agency is conducting an internal review.
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 depressed his breathing and relaxed his upper airway muscles, making him more vulnerable to cardiac arrest.
“The doctors made some medical mistakes,” he said. “But this was a rapidly evolving situation where the unexpected happened. I don’t envy them the decisions they had to make.”
Lori Ellinger wears a guitar-shaped necklace that symbolizes her late son Trea Ellinger’s passion 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 process the untimely death of her only son.
She wears a guitar-shaped necklace that symbolizes Trea’s passion for music.
She looks at old photos on her phone and remembers her childhood.
Trea Ellinger grew up in rural northeastern Maryland and worked for a concrete company after finishing high school.
Despite his problems with substance abuse, he spent much of his 20s touring the country with a traveling carnival, a job he loved.
In the months before his death, he was trying to stay fit and taking methadone to curb his opioid cravings.
His mother said he had previously been diagnosed with mental health issues including bipolar disorder and schizophrenia.
Lori Ellinger visited her son at his rehabilitation center and brought him some food the day before he died.
She said he seemed to be in good spirits, but a couple of 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, he said.
She believes he ended up sleeping on the streets that night.
The following afternoon, he was seen stumbling around downtown Baltimore, falling repeatedly and acting disoriented, according to the investigative report.
Watching the videos and reading the report, Lori Ellinger’s heart breaks for her son.
It was clear he was going through some kind of crisis, but he didn’t get a call until hours later, when a nurse told him he had already died.
“I love him and I miss him,” she said. “We had a lot of good years, but not enough.”