Alabama has trouble executing people. That trouble has caused some experts to call for a halt on executions until the state can figure out how to do it better.

Some episodes take hours. One man seemed unconscious the whole time. Another was called off due to hours of punctures that never resulted in setting up the intravenous line for the procedure. The latest took so long that the state was afraid the death warrant would expire before they could get the execution going and had to call it off.

The state’s troubles executing inmates have put a national spotlight on Alabama. And perhaps no challenge has been greater than finding a vein to start the three-drug lethal injection mixture.

The details of the lethal injection execution process are a state secret. The only glimpse into it has been when something goes wrong and the Alabama Department of Corrections makes a statement, or when a judge orders the release of certain documents.

In the most recent case of Alan Eugene Miller’s failed execution attempt on Sept. 22, the Alabama Department of Corrections was allowed to begin the procedure after the U.S. Supreme Court lifted a lower court’s injunction at approximately 9 p.m. Just before midnight, the execution was called off. The state ran out of time as the death warrant expired.

ADOC Commissioner John Hamm said that night: “Due to the time constraints resulting in the lateness of the court proceedings, the execution was called off once it was determined the condemned’s veins could not be accessed in accordance with our protocol before the expiration of the death warrant.”

When asked what exactly the department was doing from 9 p.m. to approximately 11:30 p.m. when prison officials gave up the execution attempt, Hamm wouldn’t give specifics.

While Hamm said the execution team did start trying to access Miller’s veins to insert the IV, he isn’t sure how long the team worked to try to access a vein.

It wasn’t the first time Alabama has cancelled an execution in recent years after running out of time to prepare an IV.

So why is the process of setting up an IV line and beginning an execution taking so long in Alabama?

Execution isn’t medicine

“An inmate is not a patient. And someone standing there trying to do this is not practicing medicine,” said Dr. Joel Zivot, an Atlanta-based physician and associate professor of anesthesiology and surgery at Emory University. Zivot has been involved in lawsuits nationwide revolving around capital punishment and examined the body of one Alabama man after a problematic execution.

There’s no standard time in trying to set up an IV for an execution, he said, because there is no official training in medicine to place an IV for an execution—only training on how to place one for treatment.

In a medical setting, Zivot said he would be able to tell “in the first few minutes after failing” if an IV line couldn’t be inserted and a more invasive procedure, called a central line procedure, would be necessary.

According to a redacted version of Alabama’s execution protocol, released to news organizations including AL.com in a previous lawsuit, an inmate set to die will have his or her veins accessed by a doctor after the Alabama Supreme Court issues a death warrant and sets an execution date.

Details as to who prepares the lethal injection solution, and who sets up the IV or performs the central line procedure, are redacted and have never been publicly released. While the protocol allows for two physicians to be present at the execution, it is not clear if they are usually present.

The protocol states that when the inmate is taken to the execution chamber and strapped onto the gurney, “the IV team will be escorted into the execution chamber to start the IV… If the veins are such that intravenous access cannot be provided, (REDACTED) will perform a central line procedure to provide intravenous access.”

There have been documented issues in starting an IV in at least three recent Alabama executions: The failed execution attempt of Doyle Lee Hamm in 2018, the controversial execution of Joe Nathan James Jr. on July 28, and the failed execution attempt of Alan Eugene Miller on Sept. 22.

Hamm has since died, and a judge has ordered state officials to preserve evidence from Miller’s failed execution attempt and have Miller examined for injuries.

“When you are trying to do something technical, each time you do it and you fail, it tells you something. It says that what you did was not correct and therefore you failed,” Zivot said.

Many have speculated the reason ADOC cannot set up an IV line in a timely manner is because of the training—or lack of—of the person responsible for setting up the line.

The process of sticking an inmate about to be executed is closed to media witnesses and to attorneys for the inmate. Only state representatives are allowed to witness the process.

Zivot said there could be a “perfect storm” of conditions as to why a person couldn’t quickly find a vein. It could be a coincidence this happened repeatedly in Alabama. It could be that an inmate’s veins are hard to puncture because they are small or rolling or deep. Or it could be that the people handling the procedure are not highly skilled.

Robert Dunham, the executive director of the Death Penalty Information Center, said inmates on death row are typically not the healthiest people, leaving their veins more compromised than average people. That can make it challenging to set up an IV.

In Alabama, there are 166 inmates on death row; the average age of the inmates is 55. But, Dunham said, the inmates’ health matches a person at least in their 60s due to possible prior drug use, prison conditions, lack of proper nutrition and exercise, and more.

“In short, unqualified or inadequately qualified execution personnel are given the job of setting intravenous execution lines for prisoners who are much more likely to have compromised veins and face the immediate stress of being executed,” Dunham said. “It is a recipe for disaster.”

After James was executed on July 28, Zivot examined his body during a private autopsy. The doctor said James suffered from a cutdown, or a way some medical professionals cut open a person’s arm to access a vein. Zivot said a cutdown is an old technique and suggests a certain level of skill from a person with medical training.

“That represents to me a seriously broken system here that is charged with the serious act of killing someone,” Zivot said.

The redacted version of the protocol does not mention cutdowns and only states that “the standard procedure for inserting IV access will be used.”

Zivot said a cutdown isn’t a standard way to get IV access in a medical setting, but comparing the process of starting an IV for an execution to a medical act “has obvious and important limitations.”

“Everyone is trying to play doctor here a little bit, and they are doing it poorly,” he said.

A system without oversight

The Alabama Department of Corrections has never disclosed any process that reviews executions or failed executions. “They learn nothing from each time,” Zivot said. “They do the same thing over and over again, (and) that is seemingly to inflict torture.”

Dunham said oversight could lift the veil of secrecy. In Oklahoma in 2014, the governor called for an “independent review” of the state’s execution procedures after a botched execution and halted any further executions there until the review was complete. The Oklahoma Death Penalty Review Commission was created in 2016 as an independent, bipartisan commission, according to the Death Penalty Information Center, and included people from across the justice system along with citizens and advocates on both sides of the issue.

Dunham said that is a practice Alabama should follow. He also said Alabama should allow media and other witnesses to see and hear the entire execution process, from the moment the inmate enters the execution chamber until they are pronounced dead.

Dunham previously said he isn’t aware of an execution that took as long to set up as James’ in the 40-year history of lethal injection executions.

James, put to death for the 1994 slaying of his ex-girlfriend in Birmingham, was set to be executed at 6 p.m. that evening, but the prison did not transport media witnesses to the prison until 6:33 p.m. After a delay of more than two hours, the execution began at 9 p.m. His official time of death was 9:27 p.m.

Zivot said the ADOC hides its mistakes and is unwilling to examine their process in both an impartial and public way. “All they do is they do a terrible job, and they just hide it,” he said.

Another inmate, Kenneth Smith, is set to die on November 17, despite the state’s recent issues.

Members of the media and attorneys for the condemned should be allowed to witness the procedure of setting up an inmate to die, said John Palombi, an Assistant Federal Defender for the Middle District of Alabama who handles death penalty cases.

“Unless and until Alabama is willing to admit that there have been mistakes in past executions,” Palombi said, “and make the process transparent, including letting the public know the training of people conducting the executions, it should not be executing anyone.”

Inmates in Alabama and across the country have argued in lawsuits that the death penalty violates the Eighth Amendment, which prohibits cruel and unusual punishment. The U.S. Supreme Court ruled in the 1970s that specific death penalty statutes were unconstitutional, but later allowed executions to resume under revised laws. Now, the high court often hears lawsuits on “the constitutionality of particular aspects of the death-penalty system,” according to the Death Penalty Information Center.

“The punishment is being killed. It shouldn’t be the… preparation to being killed. The leadup to it ends up being extra punishment,” Zivot said. “We owe them that we do not punish them with cruelty.”

Zivot called lethal injection a “misappropriation of the tools of the medicine,” and said there have been issues with the method since it began. He hopes the latest issues with the ADOC administering the fatal drugs will prompt investigations and public outcry.

“I’m hoping this will end it. This should be it.”

Dunham agreed. “Given Alabama’s three botched executions, Governor (Kay) Ivey should pause all future executions until an independent investigation of the executions of Doyle Hamm, Joe Nathan James, and Alan Miller are completed and the investigator issues a public report.”

The ADOC did not respond to requests for comment for this story.