On October 7, 2003, a 43-year-old male Fire Fighter (FF) responded to a fire in a two-story dwelling. After performing "up and over" ventilation (climbing two ladders to the roof and removing windows below the roof line with a closet hook), the FF had a witnessed collapse on the roof. After approximately 47 minutes of cardiopulmonary resuscitation (CPR) and advanced life support (ALS) on-scene and at the hospital, the FF died. The death certificate and the autopsy, both completed by the City Medical Examiner, listed "ischemic heart disease" as the immediate cause of death and "smoke inhalation" as a significant condition. Pertinent autopsy results included mild coronary artery disease, fibrosis of the left ventricle [consistent with remote (old) heart attack], and cardiomegaly. Other agencies have proposed a three-pronged strategy for reducing the risk of on-duty heart attacks and cardiac arrests among fire fighters. This strategy consists of: 1) minimizing physical stress on fire fighters; 2) screening to identify and subsequently rehabilitate individuals at higher risk; and 3) encouraging increased individual physical capacity. The following issues are relevant to this fire department: 1. Provide mandatory annual medical evaluations to ALL fire fighters consistent with NFPA 1582 to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others; 2. Consider requiring exercise stress tests for ALL fire fighters with two or more risk factors for coronary artery disease (CAD); 3. Phase in a mandatory wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity; 4. Ensure fire fighters wear self-contained breathing apparatus (SCBA) when working in a potentially hazardous atmosphere; 5. Ensure fire fighters wear self-contained breathing apparatus (SCBA) when working in a potentially hazardous atmosphere; and, 6. Carboxyhemoglobin levels should be tested as soon as possible on symptomatic or unresponsive fire fighters exposed to smoke.