Intensive Care: When Medicine Fights for Life

Intensive Care is a fascinating and crucial medical discipline, often associated with situations of extreme emergency. But beyond images of monitoring screens and rapid interventions, it represents a true race against time to support vital functions and offer a chance of recovery to the most critically ill patients.

Resuscitation and Reanimation: A Nuance in Terminology

In common usage, the terms "réanimation" and "ranimation" (resuscitation and reanimation) are sometimes used interchangeably, but in medicine, the former has prevailed to designate a complete specialty.

  • Reanimation (Reanimation) is an older term, often synonymous with the "action of reviving", meaning to quickly restore life or consciousness in a person in a state of apparent death (such as after drowning or cardiac arrest). It is still used in the context of first aid (e.g., cardiopulmonary resuscitation).
  • Réanimation (Intensive Care) is the preferred term today in a hospital setting. It designates the set of sophisticated techniques and treatments implemented to support (temporarily replace) one or more vital organ failures (heart, lungs, kidneys, brain, etc.) while awaiting recovery or recuperation. Intensive Care does not stop at the initial restoration; it encompasses constant monitoring and continuous treatment of the critically ill patient.

In short, reanimation is an initial emergency measure, while Intensive Care (ICU) is a complete and prolonged hospital discipline aimed at keeping the patient alive until the organism can take over again.

The Scope of the Intensivist

The Intensive Care Unit (ICU) (or Critical Care Unit) is the hospital unit dedicated to patients in immediate life danger. The role of the Intensive Care physician, or Intensivist, is to identify the failing organs and apply the appropriate support techniques.

Admission causes are varied: septic shock (generalized infection), acute respiratory distress, severe comas, consequences of major surgery, severe trauma, or recovered cardiac arrest.

Intensive Care is therefore a cross-disciplinary medicine. The Intensivist is an expert in emergency situations, but must also master cardiology, pneumology, neurology, and nephrology, as they are required to manage the failure of all these systems.

Equipment in the Service of Life

Intensive Care relies on essential, state-of-the-art technology for patient survival. An ICU room is an environment saturated with devices, each playing a crucial role:

  • The Monitor (or Scope): The Tele-Observer
    • It displays real-time vital signs: heart rhythm (electrocardiogram), blood pressure, respiratory rate, and oxygen saturation in the blood (SpO2​). It is the constant eye of the care team.
  • The Ventilator: The Mechanical Lungs
    • This is one of the pillars of Intensive Care. When the patient's lungs can no longer ensure gas exchange (often after intubation, which is the insertion of a tube into the trachea), the ventilator takes over to insufflate oxygen-enriched air and allow for the elimination of carbon dioxide.
  • Syringe Pumps and Infusion Pumps: Precision Pharmacy
    • These are electronic devices that administer medications with extreme precision and continuously. They are notably used for vasopressors (medications that maintain blood pressure) and sedatives (to make artificial ventilation bearable).
  • The Artificial Kidney (or Dialysis): Renal Support
    • In cases of acute kidney failure, extracorporeal purification machines (hemodialysis or hemofiltration) filter the blood to eliminate waste and excess fluid that the kidneys can no longer process.
  • The Defibrillator: The Electric Shock
    • Present in all units, it delivers an electric shock to restore a normal heart rhythm in case of a serious rhythm disorder.

The History of Intensive Care: From Ancient to Modern

The history of Intensive Care is that of a medical discipline that progressed slowly for centuries before experiencing a true revolution in the mid-20th century.

Antique Roots and First Principles

While attempts to "bring back to life" are ancient, they were not based on scientific understanding until the 17th century.

  • As early as Antiquity (circa 1500 BC), descriptions of procedures similar to tracheotomies are found in ancient Egypt, demonstrating efforts to clear the airways.
  • A crucial milestone was set in 1667 by the experiments of Robert Hooke, who proved that it is not simple breathing that is essential, but the supply of fresh air. This idea would become the foundation of artificial ventilation.

The Emergence of Manual Techniques

The 18th century marked the emergence of the first rescue societies in Europe, particularly for drowning victims, encouraging a more systematic approach. In 1775, the Scottish physician William Buchan described the principle of external cardiac massage in his work Domestic Medicine.

The Birth of Modern Intensive Care Medicine

The real turning point came in the mid-20th century, transforming resuscitation from a series of emergency measures into a complete hospital specialty:

  • 1952: The Polio Epidemic in Copenhagen (The Birth Certificate)
    • This year is considered the birth of modern Intensive Care medicine. Faced with the magnitude of the polio epidemic that paralyzed patients' respiratory muscles, Dr. Bjørn Ibsen established a revolutionary treatment protocol at Blegdam Hospital. Instead of using the ineffective "iron lungs" of the time, Ibsen and his team performed tracheotomies and provided prolonged manual ventilation (by positive pressure) by a rotating team 24/7, saving many lives. This experience proved the need for a specialized unit with constant personnel trained in supporting failing organs.
  • 1954: Structuring the Discipline in France
    • Inspired by the Danish work, the French nephrologist Jean Hamburger founded the first Medical Intensive Care Unit at Necker Hospital in Paris. He used this new unit not only for respiratory failure but also for acute kidney failure (with the artificial kidney) and severe intoxications, thus broadening the discipline's scope to multi-organ failures.

Standardizing Cardiopulmonary Resuscitation (CPR)

The 1950s and 1960s were marked by the culmination of efforts to standardize life-saving measures accessible to everyone:

  • 1960: The Birth of Modern CPR
    • This is the year the method systematically combining external chest compressions and mouth-to-mouth ventilation under the simple A-B-C (Airway, Breathing, Circulation) protocol was presented and adopted. This standardization, often attributed to the work of Peter Safar and James Elam, allowed for the widespread teaching of Cardiopulmonary Resuscitation to the public and health professionals.

Relational Care: The Human Element Amidst Technology

Despite the high technology, the human approach is fundamental in Intensive Care. The team (doctors, nurses, nursing assistants, physiotherapists, psychologists) is also the guarantor of the quality of relational care.

ICU patients are often sedated or unable to communicate. The team ensures:

  • Maintaining the link with the family : Regular visits and exchanges are crucial to support loved ones and, indirectly, help the patient.
  • Fighting disorientation and anxiety : A calm environment, time markers, and regular human contact are essential to prevent Post-Traumatic Stress Syndrome and delirium (acute mental confusion), which frequently occur after an ICU stay.

Ethics and Difficult Decisions

Intensive Care is also where the most complex ethical questions arise. Faced with an incurable illness or irreversible brain damage, the Intensivist must sometimes confront the issue of therapeutic obstinacy (or unreasonable persistence).

Legislation frames these situations, encouraging the limitation or withdrawal of life support (LATA - Limitation or Arrest of Therapeutic Support) when treatment becomes futile or disproportionate. These decisions, always made collegially and in consultation with the family and the team, aim to ensure that the care provided serves the best interest and respect for the patient's dignity.

In conclusion, Intensive Care is a bridge between life and death. It mobilizes technical excellence and the sharpest clinical judgment to offer a second chance, while remaining a medicine of listening and humanity in the face of extreme severity.

History and Future of Intensive Care in Togo

The evolution of Intensive Care in Togo follows a trajectory similar to that of Francophone Sub-Saharan Africa, marked by a concentration of resources in University Hospital Centers (CHUs) and a late development that has been spurred by health emergencies.

The Initial Foundations (Colonial Period – 1980)

The Togolese health system is rooted in dispensaries established during the German and then French colonial periods, with an emphasis on basic medicine and the fight against infectious diseases.

1909 : Inauguration of the "Reine Charlotte" Hospital in Lomé, a precursor to the major hospital structures.

Post-Independence (1960) : The development of hospital care became organized around the two University Hospital Centers (CHUs) in Lomé (CHU Sylvanus Olympio, the former main hospital, and CHU Lomé-Tokoin), which became the reference centers.

Up to the 1980s : Anesthesia and post-operative care constituted the initial forms of critical care, but dedicated Intensive Care Units (ICUs), with the capacity for specialized equipment and personnel, remained very limited and concentrated in Lomé.

The Emergence of Intensive Care (1990 – 2019)

The need for a modern Intensive Care structure became more pressing, but challenges persisted : a low level of equipment, a lack of trained staff, and a high mortality rate for severely ill patients.

1996: A request from the CHU Lomé-Tokoin to Japan included the need for a "New Intensive Care Center" with a capacity of 20 beds, complete with a medical gas plant and artificial ventilators. This project symbolized the institutional effort to create a genuine, modern ICU at the top of the healthcare pyramid.

2000s – 2010s : The anesthesia-intensive care and surgical intensive care departments of the CHUs continued to manage the most serious cases.

  • A study on the management of septic shock in surgical intensive care at the CHU Sylvanus Olympio, documented around 2013, highlighted an extremely high mortality rate (97.5%), underscoring the major challenges related to the lack of advanced equipment (arterial catheters) and optimal protocols in an under-resourced setting.

2012 : A study on the anesthesia practice in Togo revealed a critical lack of advanced monitoring equipment (e.g., capnography was almost nonexistent), even though private centers were generally better equipped.

The COVID-19 Catalyst and Recent Strengthening (Since 2020)

The COVID-19 pandemic accelerated investments in critical and infectious disease care infrastructure.

  • 2022 : The surgical emergency department at CHU Sylvanus Olympio was fully rehabilitated and equipped with new materials, improving the first link in the critical patient management chain.
  • 2025 (Planned) : The inauguration of the first Center for Infectious Diseases (CMI) in Kara is a major step for the health system's resilience. Although targeting infectious disease management, these centers are crucial for the isolation and intensive care of patients with epidemic pathologies requiring critical care.
  • Currently : Efforts are focused on training healthcare personnel, notably with the support of the WHO and the World Bank, to enhance the quality of critical care and the Universal Health Coverage Index (UHCI).

Togolese Intensive Care is thus developing, transitioning from a poorly equipped surgical support service to a more recognized discipline, thanks to recent investment efforts and the acceleration necessitated by global health crises.