Last night marked another horrific chapter in our nation's practice of capital punishment. In Oklahoma, two executions were scheduled for last night, following a new three-drug protocol. The first drug administered was midazolam, already used as part of a botched execution in Florida. (see my previous post on this topic for pharmacologic details and links.)

About 10 minutes into the first execution, 38-year old Clayton Lockett was declared unconscious by a physician.  According to CNN, Lockett sat up and tried to speak 16 minutes into his execution. He was seen to be writhing or convulsing on the gurney, and about 20 minutes into the process, his vein "exploded," executioners said, causing them to halt the process. At that point, guards closed the windows so the witnesses could no longer see what was happening. 43 minutes into the process, Lockett apparetly suffered a massive heart attack and died. 

The legal battle centered around a prisoner's right to know the source of the drugs to be used to execute him or her. A stay on Lockett's execution was lifted last week when a judge ruled that there was no such right. After last night's experience, executions are again on hold in OK for at least 2 weeks.

The plan was to render Lockett unconscious with midazolam, then stop his breathing (and all muscular activity) with the paralytic drug vercuronium bromide, then stop his heart with potassium chloride.

What could have gone wrong? Of course, I wasn't there, and can't speak with certainty, but here are two possibilities. 

Benzodiazepines like midazolam can rarely have paradoxical effects: a drug that usually renders one deeply sedated and relaxed, and has anti-convulsant properties, can cause agitation, anxiety, aggression, talkativeness, rage, violent behavior, and delirium, often states not recalled by the patient upon recovery. The midazolam dose used for sedation is much lower than that used for execution, but since Mr. Lockett's vein "exploded," it's unclear what dose he actually received, or, from the information given, what his actual state of consciousness was. The effects of midazolam can be reversed with Flumazenil, (a benzodiazepine-receptor antagonist) but did the executioner have a reversal agent on hand? Reversal of midazolam with Flumazenil can cause seizures. When the execution was stopped, efforts were made to resuscitate Lockett, but details aren't clear.

The other possibility is more troubling. According to protocol, after the victim is declared unconscious executioners begin injecting the second two drugs. According to OK Department of Corrections director Robert Patton, the second two drugs were being administered when Lockett began to sit up and attempt to speak. Clearly the paralytic vercuronium had no effect. But what about the potassium bromide?

Potassium chloride is the drug in this cocktail used to stop the heart. It is an acceptable drug for animal euthanasia ONLY in anesthetized animals, and is condemned as inhumane otherwise because of the pain associated with stopping the heart of a conscious animal

Did Lockett experience paradoxical excitation from midazolam, and then suffer a heart attack? Or did OK somehow manage to kill a more-or-less conscious Lockett with the effect of potassium chloride alone, a death condemned by veterinarians as too cruel for livestock? 

And when will the US finally come to its senses and stop capital punishment? The moral case against capital punishment is clear. But even if it were morally right for the state to kill its prisoners, it's becoming clearer and clearer that it just can't be done competently.

UPDATE--well, it just gets worse. This from OK department of Corrections timeline, reported in the NYTimes. Apparently after nearly an hour of hunting for a vein, the phlebotomist wound up placing a single line in Lockett's femoral vein. It is standard procedure to have two patent IV's for executions, in case one line blows. (IV catheters can go wrong in a couple ways. Most commonly, the catheter slips out of the vein or was never properly placed to start with--certainly possible in the femoral vein, a deeper and trickier vein to securely place a line in than the usual arm, hand or leg. Veins can rupture, but a slipped or misplaced catheter seems more likely.) For modesty, the injection site was covered when the injection was made. Once Lockett seemed unconscious, the second two drugs were injected, drugs which can be painful if injected outside a vein. Lockett woke up. The executioners apparently DIDN'T HAVE ENOUGH DRUGS to complete the process, given the leakage of the first dose, even if they could have found a vein. How can this be true, since a second execution was scheduled for the same night?? And how lacking in basic medical foresight.

This is more than botched--it's a disgrace, a travesty of grand proportion. Utterly, utterly incompetent.