CHICAGO — Executions by lethal injection involve a common medical procedure and government-approved medications — used for non-medical purposes. That’s one reason why the American Medical Association and several other physician and nurses groups oppose having their members participate in executions. Here’s how the procedures and drugs are supposed to work, and what can go wrong.
These are performed in doctors’ offices and hospitals to administer fluids and medication. Typically a needle-tipped catheter is inserted into a vein, through which medication is given, in single doses or continuously infused.
Vein ruptures — reported to have happened in Oklahoma’s execution Tuesday — can occur if an IV needle accidentally pokes all the way through a vein wall, or causes it to burst open, allowing IV fluid or drugs to flow out of the vein and not to the intended target — like a leak in a garden hose. That could happen under any number of circumstances, including if the patient’s arm moved during needle insertion, or if a tightened tourniquet creates too much pressure in the vein, causing it to burst like a balloon when the needle pierces it.
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In medical settings this is usually fairly inconsequential; nurses attempting to insert the IV typically would notice bruising or swelling and would then insert it in a different vein before administering medication. Experts say it occurs most often in older, sick patients with frail veins, or IV drug users whose veins have scarred, but it is uncommon in healthy younger people.
Sometimes attempts to insert an IV miss the vein entirely, allowing fluid or drugs to flow into surrounding tissue instead of into the bloodstream. That also can cause swelling and pain at the injection site, and can delay action of the medication. While IV saline is typically harmless, many medications can cause serious tissue damage if they spill out of the bloodstream and the breach isn’t treated right away.
IV injections are considered extremely safe in skilled hands. It is uncertain how much training was given to the three technicians who each administered one of three drugs used in the Oklahoma execution. According to the state’s execution protocol, the warden recruits a “licensed/certified health care specialist in IV insertion.” The identity of that person is not disclosed.
The drugs given to Oklahoma inmate Clayton Lockett were midazolam, vecuronium bromide and potassium chloride — all potent drugs with potentially serious side effects. In executions, they are typically injected in that order, at high doses.
Warning labels that accompany packages of midazolam say intravenous use of the drug has been associated with respiratory suppression or respiratory arrest. Monitoring is required in case there is a need to intervene with life-saving medical treatment. Overdoses can result in a slow heart rate.
VECURONIUM BROMIDE (paralytic)
The package labeling warns that means of providing artificial respiration and oxygen therapy should be available when patients are given vercuronium, which is often used to relax muscles for intubation or during surgery. Respiration “insufficiency” is listed as a possible adverse reaction.
POTASSIUM CHLORIDE (stops heart)
The labels include strong warnings that potassium chloride must be given at a slow, controlled rate when administered for the treatment of a potassium deficiency. At higher doses, the drug stops the heart. For non-lethal higher doses, medical literature says to discontinue the infusion immediately and use injections of dextrose and insulin, absorb excess potassium and engage in dialysis. Respiratory paralysis is also possible. Medical literature at the National Institutes of Health says potassium intoxication can cause cardiac arrest and that EKG abnormalities can illustrate trouble.
DOCTORS AND EXECUTIONS
The American Medical Association has a longstanding policy against doctors participating in executions, including selecting injection sites or starting IV lines, given their oath to “do no harm.” It also says in most cases it is unethical for doctors to be present at executions, including declaring an inmate dead. That’s because a doctor might be put in the position of saying more drugs are needed if the first doses weren’t lethal. The association says it is OK for doctors to certify a death if the inmate was declared dead by someone else, or to witness the execution if the inmate has made that request.
Oklahoma protocol calls for a physician to “monitor the condemned offender’s level of consciousness.” A doctor in the death chamber with Clayton Lockett appeared to do so.