You guys doing that right?
The key to any claim that the standard three-drug lethal injection execution is not cruel is that the anesthesia renders the inmate unconscious and unable to feel pain before the other drugs are administered. Yet corrections officials do not ensure the anesthesia is effectively administered. During surgery, a trained anesthesiologist remains at the patients side to determine whether the patient has reached the proper level of unconsciousness before the surgery proceeds, and to ensure the patient remains unconscious for the duration of the procedure.130 For reasons that remain unclear, however, state corrections agencies have not incorporated into their lethal injection executions the same safeguards that accompany the administration of anesthesia in medical procedures. State lethal injection protocols do not require execution teams to include persons trained in administering anesthesia, do not permit personnel to be close enough to the condemned inmate to monitor the administration of the anesthesia, and do not use trained personnel to determine whether the condemned inmate is properly anesthetized before the other two drugs are injected.
The basic procedure states use in lethal injection executions is as follows:131 The condemned prisoner is brought to the execution chamber and strapped to a gurney. Some states allow the witnesses to watch the executioner(s) insert the catheter into the prisoners arm.132 Other states draw a curtain over the windows behind which the witnesses sit so they do not see the execution team insert the catheter into the condemned inmate.133 The catheter is hooked up to an intravenous line that extends for at least several feet into the room where the execution team administers the injections. That room or space may or may not have a one-way mirror so that the executioners can look out at the prisoner without being seen. If the curtains were closed, they are opened. Witnesses see the prisoner alone in the chamber, already hooked up to the intravenous (IV) lines. The execution team, which consists of one or more people, will have prepared syringes with the drugs and syringes with saline solution used to flush the lines in between each drug. Upon a signal from the warden, the team begins injecting the syringes into the IV lines, one after another, in the prescribed sequence, without a break.
Some states use a more complicated procedure. For example, in Oklahoma, catheters are inserted into both arms.134 Three executioners plunge eleven syringes in a complicated sequence, alternating the drugs between the left and right arms. It is not known who, if anyone, directs the sequence of drug administration for the executioners. The process is then repeated by injecting a second round of drugs. By the end of the process, the prisoner should have received two doses of sodium thiopental through the left arm, two doses of pancuronium bromide through the right arm, and two doses of potassium chloride (one dose through each arm).
Oklahomas current method of administering the lethal drugs differs from that originally developed by Chapman. The protocol Chapman developed called for a continuous infusion of sodium thiopental and did not split the drugs between the two arms. His protocol also called for observation of the IV site. These protections no longer exist in the current Oklahoma protocol. It is not clear whether Oklahoma ever executed its inmates using Chapmans protocol, or when and why the changes where made.135 When Human Rights Watch asked Chapman if he had concerns about the ways states today were administering lethal injection executions, he noted, The question [of the drugs] being administered properly, that never came up in my mind. I never knew we would have complete idiots injecting these drugs. Which we seem to have.136
Missouri is the only state known to use a femoral venous IV, in which the IV is inserted into the femoral vein in the groin area.137 A small needle is used to inject a local anesthetic. A larger needle is inserted into the femoral vein, and, once blood is obtained, a wire is threaded through the needle into the vein, and the needle is withdrawn. Then the IV catheter is threaded over the wire and into the vein. The catheter is then secured by suture. Little is publicly known about the training and expertise of the execution personnel who perform Missouris complicated femoral IV access executions. While the limited public record indicates that a surgeon creates the IV access, it is unclear what their role is in the conduct of the execution.138 The attempts by condemned prisoners to discover the information through litigation have been rebuffed by the states refusal to answer questions posed in the plaintiffs depositions and interrogatories.139
Most lethal injection protocols say little or nothing at all about the training, credentials, or experience required of persons who will be on the execution team, either the person who inserts the catheter or the persons responsible for injecting and monitoring the drugs. No state lethal injection protocol expressly requires the team to include an anesthesiologist or someone with training in anesthesiology.
Twelve state lethal injection protocols contain no reference at all to the qualifications of the executioners.140 Eight protocols refer generally to training, competency, preparation, or practice, but they do not elaborate further.141 For example, North Carolinas protocol states: Appropriately trained personnel enter behind the curtain. But it does not explain what would constitute appropriate training.142 According to Texass protocol, a medically trained individual (not to be identified) shall insert an intravenous catheter into the condemned inmates arms.143 The frequent problems Texas executioners have had with the insertion of catheters certainly raises questions about the actual training of the individuals who insert the catheter. (See Chapter Six on Botched Executions for descriptions of such problems.) Texass protocol does not refer to the qualifications of any other participants in the execution. Californias protocol states: The angiocath shall be inserted into a usable vein by a person qualified, trained, or otherwise authorized by law to initiate such a procedure.144 Again, like Texas, there is no reference to qualifications of other members of the execution team. Similarly, Floridas protocol does not refer to the qualifications of the execution team members. Florida does require the presence of a doctor and a physicians assistant in the room, but their role in the execution is not clear.145 What is known is that Florida pays its executioner, described only as a private citizen, $150 for each execution. Florida recruits its executioners by advertising in local newspapers.146
Even though not expressly included in their protocols, a number of states have disclosed the qualifications of at least some of their execution personnel. In Pennsylvania, Colorado, and Georgia, for example, the corrections departments use trained Emergency Medical Technicians (EMTs) to insert the catheter.147 Ohio uses an EMT and a phlebotomist to start the IVs, and an EMT administers the medication.148 Tennessee uses two paramedics to insert the IVs.149 Oklahoma uses a phlebotomist to insert the IVs.150
Emergency Medical Technicians may be trained to insert catheters, but they are not ordinarily trained in the intravenous administration of anesthesia. Indeed, they may not even have a basic knowledge of the nature of the drugs they will administer. For example, Louisiana EMTs who administer the drugs during lethal injection executions have revealed they knew nothing about the drugs used in the procedure, including the anesthetic.151 The warden of Louisianas State Penitentiary, who is responsible for ensuring that the EMTs involved in Louisianas execution are qualified to perform lethal injection executions, recently stated that he has no clue as to whether the EMTs on his lethal injection execution team have been trained in intravenous administration of anesthesia.152 North Carolinas Secretary of the Department of Corrections has acknowledged that he is ultimately responsible for his states lethal injection executions.153 Yet when asked about the medical qualifications of the execution team, he stated: I dont know whatI would assume a nurse at least or someone else who is certified to insert a needle.154
The absence of appropriate medical training extends to something as basic as strapping the prisoner correctly. If the straps used to secure an inmate to the gurney are improperly secured, they can stop the delivery of the drug from the intravenous site in the prisoners arm to the prisoners brain.155 A member of Louisianas execution strap-down team acknowledged he had never received any training from medical personnel about how to fasten the straps without restricting the prisoners circulation.156 One of the botched executions in Chapter Six, below, exemplifies the problem of too-tight straps.
Because problems in drug delivery systems and equipment malfunction can lead to the ineffective administration of anesthesia, the American Society of Anesthesiologists (ASA) emphasizes the importance of having medical personnel check the functioning of the anesthesia delivery system every time it is going to be used.157 The ASA stresses the importance of having a checklist protocol for the anesthesia machines and equipment, to assure that the desired doses of anesthetic drugs will be delivered.158 We do not know how many states check their intravenous equipment before using it for executions, nor do we know the qualifications of the persons who do the checking. A warden in North Carolina admitted that, while his execution teams do have a checklist protocol, it is not used or practiced. I dont know the last time [it] was actually used.159
The nature of the set up in execution chambers also increases the possibility of problems with the equipment. All the lethal injection drugs are administered from behind a screen or wall several yards away from the prisoner. The length of the intravenous tubing itself is thus problematic, because it requires multiple IV extension sets and connectors, increasing the risk of kinks and leaks.160
The ASA (in its Practice Advisory) underscores the importance of having an anesthesiologist near the patient to in order to verify that the intravenous access equipment, including its infusion pumps and connections, are properly functioning and to visually monitor the flow of the anesthesia into the veins.161 In lethal injection executions, however, such monitoring is not possible because of the distance of the execution team from the equipment. For example, because of the distance, the executioners cannot immediately determine if the anesthesia is leaking into the surrounding muscle tissue because of an improperly inserted or secured needle.162
Finally, and most crucially, corrections agencies do not permit anyone to monitor the prisoners level of anesthesia before the second and third drugs are administered. Standard medicaland even veterinarypractice requires a hands-on determination of the depth of anesthesia of the patient, or of an animal, before the initiation of any painful procedures.163 Yet during lethal injection executions there is no one, much less someone trained in anesthesia, who either ascertains a prisoners sedation level before the next two painful drugs are administered, or who continuously monitors the inmates consciousness levels throughout the execution until the prisoner has died. Similarly, there is no one who can make necessary adjustments to dosage amounts, should a problem emerge.164
Many condemned prisoners fall within a category of persons the American Society of Anesthesiologists has deemed most at risk of experiencing intraoperative awareness because of a history of past intravenous drug use, obesity, and other factors of poor health.165 When a paralytic agent such as pancuronium bromide is used in surgery on such persons, it is especially important that anesthesiologists carefully monitor the delivery and the patients reaction to the anesthesia to ensure the patient is unconscious.166
The patients depth of anesthesia during surgery is typically assessed by a number of factors, including but not limited to the patients motor functions, responses to noxious stimuli, and reflexive responses.167 The ASA warns that when a neuromuscular blocking agent is used in combination with anesthesia, it will mask a patients response to stimuli, making it harder for a trained anesthesiologist to determine whether he is appropriately anesthetized or just paralyzed and unable to signal consciousness.168 In such situations, the anesthesiologist monitors anesthetic depth through a continuous real-time assessment of an array of physical signs and monitor signals, which may include the patients heart rate, systolic blood pressure, diastolic blood pressure, EKG waveform, EEG waveform, pupil size, and anesthetic gas concentrations, which then must all be related to the intensity of the ongoing surgical stimulation. Such monitoring is part science and part art, and it takes a considerable amount of hands-on training and experience.169 Despite the critical importance of this monitoring to ensuring a pain free execution, Human Rights Watch is not aware of any state that requires it.
In North Carolina, the warden in charge of overseeing lethal injection executions did not doubt that prisoners were sufficiently anesthetized when the other drugs were administered. During a deposition, the warden said he could tell the prisoners were anesthetized because: At the time we administer Pavulon, the inmate is snoring deeply. It is obvious that hes asleep and unaware . . . In 24 executions, I have never seen one that did not snore.170 The deposition continued:
The Secretary of the Pennsylvania Department of Corrections told Human Rights Watch that during lethal injection executions, the condemned inmates head is near the window through which the executioners can see him. This way, the executioners can see that the inmate looks asleep when they administer the other two drugs following the anesthesia.172 Yet according to Dr. Peter Sebel, an expert on measuring anesthetic depth in patients during surgery, snoring or whether the patient appears to be asleep are not adequate measures of anesthetic depth.173
Corrections officials have not publicly explained why no one with appropriate training remains alongside the prisoner to determine the effectiveness of the anesthesia before the other drugs are administered. Maybe they want to protect the anonymity of members of the execution team. But their identities can be hidden from the public through surgical caps and masks, standard issue uniforms and shoes. Maybe they want to spare someone who is participating in an execution from having to stand in intimate proximity to the person being killed. Human Rights Watch recognizes that standing alongside a person being killed wouldindeed shouldbe emotionally difficult. But corrections agencies should not put prisoners at risk of pain simply to spare the feelings of the executioners.
 Human Rights Watch telephone interview with Kevin Fagan, San Francisco Chronicle reporter and media witness to the execution of Stanley Tookie Williams, February 22, 2006. See also, Kevin Fagan, The Execution of Stanley Tookie Williams Eyewitness: Prisoner Did Not Die Meekly, Quietly, San Francisco Chronicle, http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2005/12/14/MNG05G7QMA1.DTL&hw=Stanley+Tookie+Williams&sn=003&sc=808 (retrieved April 4, 2006).
 See American Society of Anesthesiologists, Standards for Basic Anesthetic Monitoring, amended October 25, 2005, http://www.asaq.org/publicationsAndServices/standards/02.pdf (retrieved March 22, 2006).
 See, .e.g., San Quentin Operational Procedure No. 770, Lethal Injection Chamber, redacted, revised March 6, 2006, p. 33-35 (copy on file with Human Rights Watch). Individual state procedures may have minor variations.
 Interview with Fagan. See also Affidavit of Mike Mullin.
 See, Murderer of Three Women in Texas is Executed in Texas, New York Times, March 14, 1985, p. 9. In 2004, the Ohio Department of Corrections changed the location of the insertion of the catheter from the execution chamber to the holding cell. The prisoner enters the execution chamber with the catheter already inserted. Email correspondence from Reginald Wilkinson.
 Affidavit of Mike Mullin.
 E-mail correspondence to Human Rights Watch from Lisa McCalmont, April 10, 2006.
 Interview with Chapman.
 See Testimony of Dr. Mark Dershwitz, Transcript, Taylor v. Crawford, 05-4173-CV-S-FJG, January 30, 2006, http://www.mhb.com/profiles/ford/cases/PDF%20Docs/Consult-Lethal%20Injection/Taylor%20(Missouri)/01302006%201600%20Transcript%20of%20Snap%20Hearing%20w%20Drs%20Dershowitz%20&%20Groner.pdf (retrieved March 22, 2006). A Kentucky Circuit Court recently found that jugular vein catheterization violates the Eight Amendment, Baze v. Rees, No. 04-CI-01094, slip opinion, p. 11-12 (Kentucky Circuit Court, July 8, 2005).
 Brief of Appellant-Plaintiff, Taylor v. Crawford, et al., No. 06-1397, February 24, 2006, p. 33-34. See also Defendant Crawfords Answers to Plaintiffs First Interrogatory, Taylor v. Crawford, Case No. 05-4173-CV-C-SOW, September 12, 2005, p. 14-15.
 Arizona: Arizona State Prison ComplexFlorence, Execution Information (copy on file with Human Rights Watch); Arkansas: Arkansas Department of Corrections Procedure for Execution, (copy on file with Human Rights Watch); Delaware: Department of Corrections Execution Information, e-mail correspondence with Denno, April 5, 2006; Idaho: Execution Procedures, Idaho Department of Corrections Policy and Procedures Manual, Section 135, January 2004, p. 4 (copy on file with Human Rights Watch); Indiana: Summary of Execution Procedures in the State of Indiana, Indianoplis Star, http://www2.indystar.com/library/factfiles/crime/capital_punishment/deathrow.html#history (retrieved April 6 2006); Kansas: Kansas Department of Corrections LCF General Order 10,120, February 5, 2001 (copy on file with Human Rights Watch), confirmed current in Human Rights Watch telephone interview with Francis Breyne, public information officer, Kansas Department of Corrections, March 30, 2006; Maryland: Department of Corrections Execution Information, e-mail correspondence with Denno, April 5, 2006; Mississippi: e-mail correspondence with Denno, April 5, 2006 (confirming they mention only executioners in their protocol); New Mexico: Penitentiary of New Mexico Policy #073400, revised May 30, 2001 (copy on file with Human Rights Watch); South Carolina: Department of Corrections Lethal Injection Information, e-mail correspondence with Denno, April 5, 2006; Virginia: Brief for Amicus Curiae of Darikk DeMorris Walker in support of Petitioner, Hill v. McDonough, et al., March 6, 2006, http://www.law.berkeley.edu/clinics/dpclinic/pdf/Hill/2006.03.06%20amicus%20walker.pdf (retrieved April 5, 2006); Washington: Washington Department of Corrections, Capital Punishment, Department of Corrections Policy, No. 490.200 and 760.001, April 25, 2001 (copy on file with Human Rights Watch).
 California: San Quentin Procedure No. 770, revised March 8, 2006 (copy on file with Human Rights Watch); Colorado: Colorado Department of Corrections Administrative Regulation No. 300-14, August 1, 2005, http://www.doc.state.co.us/admin_reg/PDFs/0300_14.pdf (retrieved April 5, 2006) (thoroughly trained execution team); Connecticut: State of Connecticut Department of Corrections Directive No. 6.15, October 19, 2004, http://www.ct.gov/doc/lib/doc/pdf/ad/ad0615.pdf (retrieved April 5, 2006) (appropriately trained and qualified); Illinois: e-mail correspondence to Human Rights Watch from Deborah Denno, April 5, 2006 (a trained person shall insert the catheter); Montana: Montana Department of Corrections Policy No. Doc. 3.6.1, http://cor.mt.gov/resources/POL/3-6-1.pdf (retrieved April 5, 2006) (trained execution team); New York: New York State Department of Corrections, Procedures for the Operation of the Capital Punishment Unit Green Haven Correctional Facility, Section V, points. A-C, p. 7, August 3, 2001 (copy on file with Human Rights Watch) (qualified individuals proficient in starting and administering IV fluids); North Carolina: North Carolina Department of Correction, Execution Method, http://www.doc.state.nc.us/dop/deathpenalty/method.htm (retrieved April 5, 2006) (appropriately trained personnel); Oklahoma: Affidavit of Mike Mullin (trained personnel); Oregon: e-mail correspondence with Denno, April, 5, 2006 (medically trained individual).
 North Carolina Department of Correction, Execution Method.
 Texas Department of Criminal Justice Institutional Division, Public Information Office, Execution Procedures of Inmates Sentenced to Death, April 23, 2001, p. 2 (copy on file with Human Rights Watch).
 San Quentin Operational Procedure No. 770, p. 39.
 Sims v. State, 754 So.2d 657, 666 n. 17.
 Associated Press, Sims dies by lethal injection; switching from electrocution, Florida Times Union, February 23, 2000. See also, Florida Corrections Commission, Execution Methods Used by States.
 Interview with Beard. Interview with Atherton. In Colorado, the Emergency Medical Technicians (EMTs) are full-time, non-medical correctional officers at the corrections department who work part-time as EMTs in the community. Georgias use of EMTs is mentioned in: Georgia Department of Corrections Report on the History of Georgias Death Penalty, http://www.dcor.stat.ga.us/pdf/TheDeathPenaltyinGeorgia.pdf (retrieved April 5, 2006).
 E-mail correspondence from Reginald Wilkinson.
 Petitioners Brief, AbdurRahman v. Bredesen, et al., February 15, 2006, p. 2.
 Affidavit of Mike Mullin.
 The ignorance of the executioners in Louisiana was vividly displayed at a special hearing. Special Hearing, Code v. Cain, Case. No. 138,860A, September 16, 2003, excerpt testimony from anonymous trial witnesses: excerpt from John Doe #1, leader of the IV team, p. 15-16; excerpt from John Doe #2, assistant on IV team, p. 16; excerpt from John Doe #4, assistant on IV team, p. 17-18. For example, in response to a question about the effect of sodium thiopental, John Doe #1, the leader of the IV execution team responded, I read the literature that came with the product when we got it for the lethal injections. Thats been 12 years ago. I have no idea. The attorney for the defendant asked: So to summarize, would you say that its correct that you have not had a lot of training about the pharmacology of barbiturates or sodium pentothal; is that right? A: Read the literature and went over it with the pharmacist and talked to our medical director about it. Q: What do you recall from those conversations? A: Nothing. Ibid.
 Testimony of Warden Richard Peabody, Code v. Cain, p. 108.
 Testimony of North Carolina Department of Corrections Secretary Theodis Beck, Page, et al. v. Beck, et al., Case No. 5:04-CT-04-BO, August 31, 2005, p. 80.
 Ibid., p. 99.
 Interview with Heath, March 6, 2006.
 Testimony of Johnny Butler, former member of a Louisiana State Penitentiary Execution Team, Special Hearing, Code v. Cain, No. 138,860-A, February 10, 2003, p. 76.
 ASA Advisory, p. 9.
 Ibid., p. 10.
 Testimony of Warden Richard Polk, Page, et al. v. Beck, et al., Case No. 5:04-CT-04-BO, August 31, 2005, p. 114.
 Declaration of Dr. Mark Heath, Affidavit, Morales v. Hickman, January 12, 2006, p. 11-12.
 ASA Advisory.
 American Society of Anesthesiologists, ASA Standards for Basic Anesthesia Monitoring, revised October 25, 2005, http://www.asahq.org/publicationsAndServices/Standards/02.pdf (retrieved March 31, 2006); 2000 Report of the AVMA Panel on Euthanasia.
 ASA Advisory, p. 15.
 Ibid., p. 7-8.
 Ibid., p. 21-23.
 Ibid., p. 2.
 E-mail correspondence to Human Rights Watch from Heath, March 16, 2006.
 Deposition of Marvin Polk, Page, et al. v. Beck, et al., Case No. 5:04-CT-04-BO, August 31, 2006, p. 39-40. The warden also said that he asked the condemned prisoner to count backwards; when they stopped counting, that was how the warden knew the condemned inmate was anesthetized.
 Ibid., p. 40.
 Interview with Beard.
 E-mail correspondence to Human Rights Watch from Dr. Peter Sebel, professor and vice-chair, Department of Anesthesiology, Emory University School of Medicine, April 4, 2006.