DURHAM, NC – Acknowledging they were within the 4.5-hour window since symptom onset and had no other clear alternatives, a Code Team at Duke University Hospital pushed tPA in the hopes of lysing the clogged staff bathroom on the fifth floor.
“Things looked dire. Nurses, doctors on the floor thought of, tried everything. They had no choice but to call a Code. I mean, the toilet bowl was filled with stool and the water was filled to the brim,” said third-year medicine resident, Dr. Marie Andrews, still sweating bullets from the tension-filled situation. “The toilet was on the verge of spilling onto the bathroom floor. We had no other choice; tPA is indicated when a toilet is acutely clogged due to submassive-to-massive stool burden.”
The Code Team bolused the unstable toilet bowl with “a sh*t ton” of tPA, enough to be effective but small enough in volume to not cause the toilet to overflow. Nervously, they watched and waited.
Also known as alteplase or recombinant tissue plasminogen activator, tPA is a thrombolytic agent used to treat patients with acute ischemic stroke, STEMI, and hemodynamically unstable acute pulmonary embolism. However, it’s most common use is off-label: it is a health care professional’s best bet when the toilet just won’t flush.
After a few minutes, we heard some “aquatic farts” suggesting the tPA was working. Slowly but surely, the water level in the toilet bowl started to drop. After four minutes, flow exponentially picked up and the toilet started to drain completely.
“Shall I press it?” asked Holly Rankin, the nurse on the Code Team, gesturing towards the toilet bowl handle.
“Yup, that’s the next step in the algorithm,” Andrews confirmed. “Cross your fingers and hope for complete toilet reperfusion.”