IELTS Academic Reading Practice Test 405

In the industrial towns of nineteenth-century Britain, a serious accident was often followed by a long and anxious wait. A worker who fell from scaffolding, a miner overcome by gas or a child knocked down by a cart might be carried home and left until a doctor could be found. Meanwhile the bleeding was staunched with whatever came to hand, and a broken limb was tied to a board. Hospitals were few and often distant, and the earliest ambulances were little more than handcarts. The phrase 'first aid', borrowed from military medicine, entered the English language only in the late nineteenth century, and so did the idea that ordinary people could be taught to provide it.

The organisation that did most to spread that idea was the Order of St John, which traced its origins to a hospital founded in Jerusalem in the eleventh century to care for pilgrims. The English branch of the order was revived in the nineteenth century, and in 1877 a group of its members met in London and established the St John Ambulance Association. Its aim was not to build hospitals but to teach, giving ordinary men and women the knowledge they needed to keep an injured person alive until medical help arrived. Sir John Furley, a member of the order with long experience of relief work in wartime, was among those who pressed hardest for the scheme, arguing that trained bystanders could prevent many deaths.

The Association's method was straightforward. A doctor gave a course of lectures in a town hall or a schoolroom, using diagrams, bandages and simple splints, and at the end the students sat a written and practical examination. Those who passed received a certificate, and the letters after their names became a familiar mark of competence. A handbook was produced for class use and went through many editions. The Association also sold equipment at modest prices, so that a factory or a railway station could keep a stretcher, dressings and clean water ready for emergencies. In those years the word 'ambulance' still meant a mobile hospital rather than a vehicle, and much of the Association's early work consisted of teaching people how to move an injured patient without making the injury worse.

The classes spread quickly through industrial Britain. Railway companies, collieries and textile mills were natural customers, since their workers were exposed to machinery, fire and falling rock, and some employers paid for instruction as a form of insurance against accidents. Women were admitted to the classes from the early years, and many went on to teach first aid themselves. The appeal of the movement lay partly in its modesty: it did not claim to replace doctors, only to fill the gap before one arrived, and it offered a practical skill that could be learned in a few evenings.

In 1887 the Association created a uniformed body, the St John Ambulance Brigade, whose members drilled regularly and offered their services at public gatherings. Brigade members could be seen at football matches, race meetings and railway stations, carrying stretchers and wearing distinctive uniforms. Local newspapers reported the drills, and a uniformed column marching through a town on a Saturday became a familiar part of civic life. The following year the order received a royal charter from Queen Victoria, and the monarch has remained its sovereign head ever since. The Brigade gave the movement a visible presence in public life and a reserve of trained volunteers who could be called upon in an emergency.

The model travelled. Branches of St John Ambulance were established in many parts of the British Empire, from Canada and Australia to India and South Africa, and local associations adapted the lectures to local conditions. In some colonies the first organised instruction in first aid was given to police officers and to staff of the railways, who were often the only people present when an accident occurred. Translations of the handbook appeared in several languages, and visiting lecturers were sent out from London to train local instructors.

War gave the movement its largest test. St John volunteers served in the South African War of 1899 to 1902, and in 1914 the Brigade joined with the British Red Cross to form a single organisation for wartime relief, running hospitals, ambulance trains and convalescent homes. The experience strengthened the case for training large numbers of people, and after the war the Association's classes became a familiar part of factory life, evening institutes and youth organisations.

The twentieth century brought new reasons to learn first aid. As roads filled with motor traffic, injuries that had once happened mainly in workplaces began to happen in streets, and the treatment of shock, burns and fractures became part of the standard syllabus. Instruction in resuscitation was added later, once modern techniques of artificial ventilation and chest compression had been developed in the middle of the century. What had begun as a Victorian philanthropic project became, in many countries, a routine part of safety training at work.

The Association's founders would perhaps be surprised by the scale of what they began. St John Ambulance now trains large numbers of people each year, and its volunteers remain a familiar sight at public events. Yet the principle established in 1877 has not changed. The first few minutes after an injury are often the most important, and the person who can help is usually not a doctor but whoever happens to be nearby.

Blood performs several jobs at once: it carries oxygen and nutrients to the tissues, removes waste, distributes heat and brings the cells and proteins that seal a wound. Losing a large quantity of it therefore threatens every organ at the same time. An adult of average size holds roughly five litres, and the body treats the loss of more than a small fraction of this as an emergency. What follows is not a single reaction but several overlapping ones, some beginning within seconds and others unfolding over days and weeks. Together they buy time, but none of them can replace the blood that has gone.

The first response is a reflex. Pressure sensors called baroreceptors sit in the walls of the carotid arteries in the neck and of the aorta, and they fire continuously, telling the brainstem how much blood is reaching the circulation. When the volume falls, the rate of firing drops, and the brainstem answers by increasing the activity of the sympathetic nervous system. The heart beats faster and more forcefully, and the small arteries supplying the skin, the gut and the muscles narrow, which raises the resistance against which the heart is pumping and helps to hold pressure up. The veins, which contain most of the body's blood at rest, tighten as well, pushing their contents back towards the heart so that it has something to pump.

This compensation is impressive, and it is why a bleeding patient can be more seriously injured than they appear. In a healthy young adult, blood pressure may stay close to normal until a third or more of the blood volume has gone, after which it can collapse abruptly. Children are particularly deceptive: they maintain their pressure for longer and then deteriorate very quickly. Doctors therefore look for earlier signs, such as a rapid, weak pulse, cool and pale skin, confusion and a delay in the capillaries refilling after the skin is pressed. Researchers are testing instruments that detect loss before the pressure falls, by analysing the shape of the pulse wave, but none has yet replaced careful observation.

The body also refills the circulation from within. As pressure in the capillaries falls, fluid is drawn from the spaces between the cells into the bloodstream, a process known as transcapillary refill. This can restore a surprising amount of volume within hours, and it explains why a patient may feel faint on standing but recover on lying down. The fluid is essentially salt water, however, and it carries no red cells and no clotting factors. The blood remaining in the vessels is consequently diluted, so that the concentration of haemoglobin, the protein that carries oxygen, may look almost normal at first and fall over the following day or two. A normal reading taken immediately after an accident can therefore be misleading.

Hormones take over next. Reduced blood flow to the kidneys prompts them to release renin, an enzyme that sets off a chain of reactions producing angiotensin, which constricts blood vessels powerfully, and aldosterone, which makes the kidneys retain sodium and water. The pituitary gland releases antidiuretic hormone, which reduces the production of urine. The small amount of fluid taken in as food and drink is thus kept in the body rather than excreted, and the patient becomes thirsty. Urine output is one of the measurements doctors use to judge whether the circulation is coping.

Replacing the red cells takes much longer. The kidneys produce erythropoietin, a hormone that travels to the bone marrow and stimulates the production of new red cells. Output increases within days, but a red cell lives for about four months and the marrow cannot work fast enough to restore the count quickly. It may be several weeks before the number of red cells returns to normal, and longer if the patient's iron stores are low, because iron is needed to make haemoglobin. This is why fatigue after a serious haemorrhage can persist long after the wound has healed.

Meanwhile the bleeding itself has to stop. Platelets, small fragments of cells circulating in the blood, stick to the damaged wall of the vessel and to one another, forming a plug. A cascade of clotting factors then converts a soluble protein into threads of fibrin, which strengthen the plug into a clot. In a severe injury this system can fail. Blood loss cools the body, and clotting enzymes work poorly at low temperature; a lack of oxygen produces acid, which has a similar effect; and the clotting factors themselves are diluted and consumed. Doctors call this combination the lethal triad of hypothermia, acidosis and coagulopathy, and it is one reason why patients who bleed heavily die.

Treatment reflects all of this. Lost volume is replaced with fluids and, where possible, with blood products given in a balanced ratio, while the source of bleeding is controlled by surgery or direct pressure. In 2010 a large international trial known as CRASH-2 reported that tranexamic acid, a drug that stops clots from breaking down, reduced deaths among injured patients who were bleeding, provided it was given within three hours of the injury. Ambulance services have also revived the tourniquet, long regarded as a last resort, after military experience showed that it saves lives when a limb is bleeding heavily. What remains disputed is how much fluid to give before bleeding is controlled: some evidence favours giving less, so that a higher pressure does not dislodge a clot, but the balance is delicate and differs between patients.

In most developed countries, a person whose heart stops outside hospital has a poor chance of surviving. The outcome depends less on the ambulance service, which may take several minutes to reach the scene, than on what the people nearby do in the interval. That is the strongest argument for a campaign that has gathered pace over the past two decades: that every child should be taught basic first aid at school. I support it, but only in a form far narrower than most of its advocates propose.

The case rests on a simple fact about time. Permanent brain damage begins within a few minutes of the heart stopping, and the chest compressions of cardiopulmonary resuscitation, or CPR, can keep oxygenated blood moving until a defibrillator or a paramedic arrives. In most cities, however, the ambulance response is measured in eight or ten minutes. Bystanders are therefore the only resource available in time, and studies of bystander behaviour suggest that most people who fail to help are not indifferent but frightened: they do not know what to do, and they are afraid of making matters worse.

The evidence that training can change this is genuinely encouraging. Denmark made CPR training compulsory in schools in 2005, and the proportion of people who received bystander CPR after an out-of-hospital cardiac arrest rose substantially, as did survival. In England, first aid and CPR became part of the curriculum for state schools in 2020. Campaigners in several other countries have pressed for similar laws. Several of these countries have since introduced comparable requirements, though the content of the lessons and the number of hours devoted to them vary widely. It is worth being precise about what such examples show: a national effort can shift behaviour, but they are not controlled experiments, and other changes in emergency care were happening at the same time.

A second argument is that children are efficient learners and effective messengers. A child taught to put an unconscious adult into the recovery position takes that knowledge home. There are documented cases of children acting correctly when a parent collapsed, and of school lessons prompting families to buy smoke alarms or learn where their nearest defibrillator is kept. Lessons also shape attitudes: a pupil who has practised compressions is more likely, years later, to begin them without hesitation.

Against this, three objections are raised. The first is time: curricula are crowded, and every hour given to bandaging is an hour not given to reading or mathematics. The second is money, since manikins, training kits and staff time all cost something, and in poorer districts the money has to be found from elsewhere. The third, and in my view the most serious, is that skills decay. A pupil who learns compressions at thirteen and never practises them again will be slow and unsure at thirty. A single compulsory course is therefore not an education but a gesture. Advocates reply that a course need take only a few hours of physical education, which few would regard as wasted.

There is also a worry about burden. Some teachers fear that children will feel responsible for outcomes they cannot control, or that a pupil will attempt something dangerous and be blamed for it. I have found little research on how pupils actually feel about this, and none that convinces me the risk is great, provided lessons stress that calling the emergency services is the first and most important step. The opposite danger - children who stand by because they assume that someone else will help - is far better documented.

The strongest objection, however, is not to first aid lessons themselves but to the claims made for them. Politicians like to say that compulsory training will save thousands of lives, but the evidence for effects on national death rates is patchy, because several improvements tend to arrive at once: faster ambulances, public defibrillators, better hospital care. What can be shown is that more bystanders attempt CPR, and that they do so more competently. It is reasonable to infer that this saves lives; it is not reasonable to present the inference as a measured result. That distinction matters, because a policy sold on an exaggerated promise is easily abandoned when the promised results fail to appear.

How, then, should such a scheme be designed? Narrowly. Four or five practical skills are enough: recognising that someone is unresponsive and not breathing normally, calling for help, pushing hard and fast on the centre of the chest, dealing with choking, and controlling severe bleeding with pressure. The lessons should be short and repeated at several ages, largely hands-on, and taught with the help of visitors - paramedics, older pupils, sports coaches - rather than left to overburdened class teachers. Whether the lessons begin at five or at eleven matters much less than that they happen at all.

I would therefore make first aid a statutory part of the curriculum, but I would not pretend that it will transform survival rates on its own. Nor would I let it crowd out what has to accompany it: refresher sessions, and a school culture in which helping is normal. A law requiring one course, taught badly and never revisited, would do less good than many campaigners suppose. It might, by creating the illusion that the job has been done, do some harm. The strongest version of the campaign, in other words, is also the most modest one.