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Investigation finds officers warned Baltimore medics about prone positioning before patient death

Investigators determined officers in the ambulance were observers and medics were in charge

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Maryland Office of the Attorney General

By Darcy Costello
Baltimore Sun

BALTIMORE — Baltimore Police officers inside the ambulance where a Glen Burnie man was restrained in a prone position told medics it would be better to position him on his side, according to an Independent Investigations Division report.

Medics “acknowledged the officers’ statements but continued taking vitals and providing aid … without moving him,” the report said.

Shortly after, a medic noticed Trea Ellinger’s lips were blue and the team began life-saving measures. According to the report, he regained a pulse but then died a few hours later at a hospital. Ellinger was 29 years old.

The Baltimore State’s Attorney’s Office said last month that the police who handcuffed and helped restrain Ellinger would not face criminal charges. The report released Thursday by the Independent Investigations Division, a part of the Maryland Attorney General’s Office, adds additional details about Ellinger’s in-custody death July 26. The division investigated the actions of law enforcement officers but does not investigate non-law enforcement participants, including medics.

Investigators wrote in the report that Baltimore Police officers in the ambulance were “primarily observers” and suggested that medics were the ones in charge of the situation.

“The officers’ actions or inaction should be evaluated in the context of the medics arriving on scene first, actively providing medical care to Mr. Ellinger and seemingly being primarily responsible for the situation throughout,” investigators said.

The report described, based on police body camera footage from the scene, that the medics asked arriving police officers to handcuff Ellinger. Shortly after, one of the medics injected a sedative into his shoulder. He then was placed on his side on a stretcher and strapped down.

Ellinger attempted to flail as that happened, and “this movement by Mr. Ellinger shifted him from his side onto his stomach,” the report said. He would remain on his stomach for about eight minutes.

It’s unclear whether any investigation was done of the medics’ role in Ellinger’s death. Neither medic faces criminal charges, according to an online courts database. A Baltimore Police spokeswoman said Thursday she had no information on whether they were ever criminally investigated.

A Baltimore Fire spokesman did not respond immediately to a question about whether any internal investigation or review was done.

Ellinger’s cause of death was mixed drug intoxication, according to the Office of Chief Medical Examiner, while his manner of death was undetermined. A final autopsy report described by the Independent Investigations Division found that Ellinger died from the combination of methadone and bupropion, and that he had a smaller amount of midazolam in his system.

Methadone is a drug used for both pain relief and the treatment of opioid use disorder. It can reduce opioid cravings and withdrawal, according to the CDC. Bupropion is an anti-depressant also known as Wellbutrin.

Midazolam, meanwhile, was the sedative administered by medics. Also known in the U.S. as Versed, it leads to sleepiness or loss of consciousness and can relieve anxiety before medical procedures, according to the Mayo Clinic .

An investigation last month led by The Associated Press found that giving sedatives to people detained or restrained by police has resulted in some avoidable deaths. The AP identified 94 people who died after they were given sedatives and restrained from 2012 through 2021, which made up more than 10% of the 1,000 deaths it found stemmed from police interactions not supposed to be fatal.

The AP reported that medical officials have viewed the sedatives as “benign treatments,” but some now say they could be playing a larger role and deserve greater scrutiny. Critics say “forced sedation” should be limited or banned, as the medications are risky to be administered in police encounters without consent, the AP report said.

In Ellinger’s case, several officers and one of the medics on scene reported suspecting he was under the influence of an unknown substance, potentially a narcotic. He was described as combative and uncooperative. One officer wrote in an incident report that there were pills scattered around him where he was “rolling on the ground screaming and clawing on the pavement.”

A 911 caller initially reported there was a man lying in the street “trying to kill himself” and “fighting people.”

Ellinger also was restrained in a prone position, the medical term for lying flat-facedown. Baltimore Police policies bar officers from leaving a handcuffed detainee in that position. Researchers say restraining someone in a prone position restricts breathing and can lead to cardiac arrest.

Body camera footage released last year captured the moments leading up to Ellinger entering the ambulance but cut off when he was inside. Outside the ambulance, a paramedic was heard warning officers not to restrain the 29-year-old with his face down.

Treating patients in-custody:
Risk management expert Gordon Graham discusses the protocol for medically treating patients who are in the custody of law enforcement

The Independent Investigations Division does not quote what officers suggested to medics inside the ambulance about positioning Ellinger on his side. It does describe that one medic told another, “Get his face out of that damn thing,” referring to the stretcher. The other responded he would “try and get him on his side in a second” but then continued attempting to get a blood sugar sample.

A legal analysis done by the Independent Investigations Division stressed that officers were deferring to medical professionals on Ellinger’s medical care.

“Officers handcuffed Mr. Ellinger at the medics’ request, positioned him on his side while he was in the street, attempted to do so when placing him on the stretcher until he rolled onto his stomach, and the BPD officers suggested to medics that they move Mr. Ellinger onto his side when he was in the ambulance,” the report said.

Attempts to reach Ellinger’s family Thursday were unsuccessful.

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