Why Lethal Injection Has an IV Problem Epidemic
The protocols, the providers, and the patients make for the worst mix imaginable.
Last week, ahead of Ivan Cantu and Thomas Creech’s planned executions, I misspoke: with the Supreme Court unlikely to produce a stay and neither the Texas nor Idaho governors amenable to clemency, I called any event that could postpone their deaths beyond February 28th “wholly unforeseeable.“
While I was referring to legal and procedural moves that could keep them alive, the fact is that a completely foreseeable event caused Creech’s execution to go awry: Despite 40 minutes of effort, Idaho’s execution “Medical Team“1 was unable to insert an IV and was forced to call off the execution.
The problem is far from new, even recently. As mentioned in a footnote last week, Alabama has escorted a man into the death chamber, only to bring him back out for failure to place an IV line, twice in as many years. Arizona so badly botched getting a line in Murray Hooper that he turned to the witness gallery and asked, “Can you believe this?“ Charles Walker’s IV was inserted backward (a sub-rookie mistake) in Illinois. In perhaps the most famous botched execution, a medic struggling to find a suitable vein didn’t notice she hadn’t hit Clayton Lockett’s femoral vein, resulting in delayed administration and a long and painful execution.
So what’s going on?
They’re Not Sending Their Best
While Idaho is ahead of some states in at least requiring some level of expertise for their lethal injection medical teams, those requirements are fairly weak. State policy requires “at least three years of medical experience“ for members of the “Medical Team,” including “venous access proficiency“ and “administering IV drugs.“ This requirement is weaker, however, than it may look. The policy considers EMTs, who are not certified to give IVs at all within their initial scope of training2, to meet this requirement, as do phlebotomists, whose training revolves around uncomplicated veins. Since Idaho joins many more states in focusing much more attention on the public never finding out who performs its executions, we’re unable to know the training levels of the people involved.
Creech’s legal team, however, said in late 2022 that “four EMTs and two registered nurses“ comprised their execution “Medical Team,“ meaning that the team designated to start Creech’s final IV was two-thirds not inherently qualified even to do it and one-third members of a profession with a first-pass success rate of 44%.
Death Row Is Not Your Average Patient Population
That first pass statistic, by the way, comes before you consider the venous access issues imposed by death row conditions. Venous access gets more difficult with age; the average death row inmate is 54 when their execution finally comes around. Death row inmates are also prone to have histories of drug use, forming scars that make access impossible at easier sites like the antecubital (crook of the elbow) or hand. They’re also more likely to be obese, have terrible diets, are prone to chronic dehydration, and definitionally live chronically sedentary lifestyles, all of which are cause poor blood flow and subsequent vasoconstriction, meaning a vein will be thinner and harder to find.
Hell or High Water
So what happens when they can’t find a vein? The answer should shock you (but won’t if you’ve paid minimal attention to the death penalty discourse).
In executions like Clayton Lockett’s, executioners moved on from peripheral to central veins, which carry more blood and are consequently larger. Cannulating these veins, however, is more difficult, and usually reserved for specialty teams or higher-level providers like those at the critical care paramedic level. In Lockett’s case, attempts to preserve his “dignity” by covering the exposed groin needed to access his femoral vein led to a lack of monitoring at the site; the vein collapsed, leading to drugs being absorbed by the surrounding tissue (which can lead to distribution of drugs but at much lower efficiency).
When even central lines fail, the process only gets more brutal. Though several states have since banned the procedure, Alabama in 2022 attempted a saphenous vein cut-down on Joe Nathan James, in which skin and muscle are cut away in order to expose the vein. The procedure is not only excruciating and barbaric, it’s even more complicated than the other options and on its way out in legitimate medicine; one critical care professor looked at me like a lunatic for even asking for assistance with performing one on a cadaver.
Can Anything Be Done?
There may be options to place IVs in lethal injection subjects that don’t involve horror stories. Intraosseous infusion, which involves drilling through bone to access the bloodstream through the marrow, isn’t as bad as it sounds (though I’ve seen it wake up an overdose) and is easier, with a little training, than placing an IV. The investigation into Lockett’s execution also recommended point-of-care ultrasound be available to lethal injection teams in order to assist them with placing a vein. The latter, however, would require more training than the aforementioned bare-minimum volunteers might be capable of; the former would be beyond the scope of practice of most of Idaho’s team as we know it.
Of course, there’s also the option of ceasing to pretend we can commit homicide politely.
This is a verbatim description of the team from Idaho’s protocol; my feelings on the conflation of lethal injection and actual medicine can probably be inferred.
Though the National Registry does not train EMTs to start IVs, many states allow separately trained EMTs to do so. What I’ve found for Idaho suggests otherwise; at any rate, it wouldn’t be the kind of regular practice necessary to deal with difficult patients.