Seven Needles: What Went Wrong in the Christa Pike Execution

Editor’s note: This piece examines nursing practice standards, professional ethics, and documented procedures as they apply to Tennessee’s September 30, 2026 execution attempt. It does not take a position on capital punishment.

Tennessee’s execution team could not get 10 grams of pentobarbital into Christa Pike’s bloodstream. The reporting since September 30 gives nurses who place IVs and manage symptoms every shift a detailed look at what the state’s protocol left out.

On the night of September 30, Tennessee’s execution team spent about an hour trying to establish IV access on Christa Pike and used at least seven needles in her left arm, her attorney Randy Spivey, who witnessed the insertion, told reporters the next day. The team then pushed two full sets of pentobarbital, 10 grams in all, according to the prison’s own call to 911.

Pike, 50, did not die. She spent days on a ventilator and was discharged back to prison on October 10 with burns and blistering on her arms, her lawyers said. Within hours, Gov. Bill Lee paused executions for the rest of 2026 and ordered a “comprehensive, third-party review.” By that weekend, Frank Strada, the Department of Correction commissioner who led development of the current protocol, said he would step down. The department says it followed every step of that protocol.

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What the Standard Says

In clinical practice, a peripheral IV start is governed by the Infusion Nurses Society’s Infusion Therapy Standards of Practice. The standards recommend no more than two unsuccessful attempts per clinician before handing off to someone with greater skill, call for ultrasound guidance rather than repeated blind sticks when access is known to be difficult, and direct the clinician to assess the site throughout an infusion and stop at once if infiltration, fluid entering the tissue around the vein, is suspected.

Pike’s lawyers had told the courts since January that she had “small veins that make insertion of needle difficult” and a platelet disorder. Under the standards, that history calls for a vascular access specialist before the first attempt, not after the seventh.

At 7:34 p.m., eight minutes after the blinds opened, Pike raised her head and said her arm felt like it was about to burst, media witnesses reported. She also asked, “Please try up on my shoulder higher.” Her arms were left burned and blistered, her lawyers said.

Dr. Joel Zivot, an anesthesiologist retained by her defense, wrote in a New York Times guest essay that pentobarbital is highly alkaline and causes a severe chemical burn in tissue, and that the pattern “suggests that at least some of the pentobarbital entered the tissue of her arms rather than her bloodstream because the intravenous lines failed.” Enough reached her brain to sedate her deeply, he wrote, but not enough to stop her breathing.

To a nurse, burning during a push, swelling, and later blistering are the recognized signs of infiltration and extravasation, and the response is to stop and re-establish access. Pike’s lawyers wrote in a court filing that “apparently at no point did any member of the execution team realize that the IV lines were not correctly placed.”

Tennessee’s 2025 lethal injection protocol says the IV team that places the lines “consists of at least two members” who may be physicians, physician assistants, nurses, EMTs, paramedics, military corpsmen, “or other certified or licensed personnel,” all “currently certified, licensed and/or qualified within the United States to place IV lines.” It names no training for them and does not say who verifies the qualification.

The department’s own Special Operations Team, which pushes the syringes and monitors the lines, must receive “training in vascular access/IV therapy by a qualified third party,” updated annually. The Nashville Banner, which reviewed the court file in June, reported that the certificates in the record came from a four-hour workshop.

Monthly rehearsals simulate every step with one exception written into the protocol: “No IV is inserted into the person playing the role of the inmate.” The 2018 protocol had no such exception, the Times reported.

The current protocol contains no consciousness check and no instructions for a prisoner who survives the second set of syringes. When staff called 911, about an hour after the drugs were given, dispatchers at first questioned whether the caller was “just, basically, prank calling,” recordings obtained by WPLN show.

The protocol gives its physician two duties: “determining that the inmate is deceased using accepted medical standards and establishing central line IV access if necessary.” The physician for Pike’s execution, Dr. Mark Fowler, confirmed in August that he would serve. He had also been the physician for the May attempt on Tony Carruthers, in which the team could not establish IV access in about an hour and Fowler’s own attempt at a central line failed.

In an October 2025 deposition, he said he had not placed a central line since leaving emergency medicine in 2013. He told NPR in September that “the doctor does not participate in the execution. The only thing the doctor does is declare the person dead.”

The American Medical Association’s Code of Medical Ethics says a physician “must not participate in a legally authorized execution,” counts selecting injection sites, starting IV lines, monitoring vital signs, and supervising lethal injection personnel as participation, and permits certifying death only “provided that the condemned has been declared dead by another person.”

The American Nurses Association’s position statement, reaffirmed in 2024, names inserting the IV catheter, monitoring the procedure, injecting the solution, and pronouncing death among the acts nurses must not perform. More than 40 Tennessee doctors and nurses asked the governor this summer to remove health workers from the protocol.

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I have done both of the jobs that failed on September 30.

As a home infusion nurse, I started IVs alone in people’s living rooms, and the two-attempt rule was the rule I worked under: two sticks, then I stopped and called for someone with more skill. A third was not mine to take because I wanted one.

As an inpatient hospice nurse for more than a year, I never placed a peripheral IV at all. Our patients were too sick for reliable peripheral access, so if someone arrived with a port or a central line, we used it. If not, we placed a subcutaneous catheter from a dedicated kit and gave comfort medications that way. None of it was solitary work. It took routine assessment of the site and the patient, orders I could titrate, a physician on call, and someone who answered the phone at 3 a.m.

Hospice does not stick a patient with fragile veins seven times. It chooses a route that will work, and someone checks it.

Lee called the review “comprehensive” and “third-party.” As of October 23, the state has not named who will conduct it or published its scope.

The physical evidence is already under court order. Davidson County Chancellor I’Ashea Myles ordered the state to preserve syringes, drugs, IV lines, log books, video, and staff messages, and Pike’s lawyers have asked for the execution team’s training and employment records. The department maintains it followed every step.

Her lawyers’ statement that night listed “difficult vein access, blown veins, degraded pentobarbital, no emergency medical care available when things inevitably go wrong.” For nurses, the questions the review must answer are the ones asked on every shift: who assessed the site, who counted the attempts, and who was qualified to decide when to stop.

🤔 Nurses: have you ever had to be the one who said “stop, this isn’t going to work”? Share your experience in the comments.