On May 30, 2005, at 2203 hours, a 39-year-old male volunteer fire fighter responded, with his lights and siren operating, to a motor vehicle fire. The call was cancelled 10 minutes before he arrived on the scene. He returned home and went to work the next day. While visiting relatives after his work shift, the fire fighter experienced pain in his chest and left arm. 9-1-1 was called, and ambulance paramedics found him lying on the ground with severe chest pain. The paramedics administered oxygen and applied a cardiac monitor, but during transport to the local hospital's emergency department, he became unconscious with a rhythm of ventricular fibrillation. Despite cardiopulmonary resuscitation (CPR) and advanced life support (ALS) performed in the ambulance and the emergency department for 40 minutes, the fire fighter was pronounced dead on May 31, 2005 at 1722 hours. No autopsy was performed. The death certificate completed by the attending physician stated the cause of death as "acute myocardial infarction" (otherwise known as a heart attack) due to coronary artery disease (CAD). This fire fighter had a known history of CAD since age 32. He had two angioplasty procedures with stent placements in 1998 and 2005. The NIOSH investigator concluded that the fire fighter's heart attack was due to his underlying CAD, probably triggered by his regular job duties. However, contribution from responding to the vehicle fire 18 hours earlier cannot be ruled out. NIOSH investigators offer the following recommendations to prevent similar incidents and to address general safety and health issues: 1. Provide mandatory pre-placement and annual medical evaluations to ALL fire fighters to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others. 2. Ensure that fire fighters are cleared for duty by a physician who is knowledgeable about the physical demands of fire fighting, the personal protective equipment used by fire fighters, and the various components of NFPA 1582. 3. Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA) as part of the fire department's medical evaluation program. 4. Phase in a mandatory wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 5. Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are physically capable of performing the essential job tasks of structural fire fighting. 6. Review EMS treatment protocols for acute myocardial infarction.