On November 29, 2006, a 38-year-old male volunteer deputy chief responded to his second fire in less than 2 hours then returned home, complaining of flank pain. Later that day, he was diagnosed with a kidney stone, admitted to the hospital for pain management, and scheduled for surgery (cystoscopy) the next morning. Just after midnight, hospital staff found him unresponsive in his bed. A code was called and despite advanced life support including external pacing, he could not be revived. No autopsy was performed. The death certificate completed by the attending physician stated the cause of death as "acute myocardial infarction" (heart attack). The NIOSH investigator agrees with the conclusions of the attending physician. It is unlikely any of the following recommendations could have prevented the deputy chief's death. However, NIOSH investigators offer these recommendations to reduce the risk of job-related heart attacks and sudden cardiac arrest among other fire fighters: 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 [NFPA 2007a]. 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 and 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 that fire fighters are capable of performing the essential job tasks of structural fire fighting.