On June 4, 2007, a 53-year-old male career Engineer participated in physical fitness training as part of the Fire Department's physical fitness program. During the fitness period, his engine company was dispatched to three calls. After the third call, and after completing the fitness training, the crew drove to a restaurant for lunch. While ordering food the Engineer gave his money to a crew member and walked outside to call his wife. As he walked outside, he collapsed. A customer entered the restaurant and alerted the fire fighters that "someone was down on the sidewalk." The crew members found the Engineer unresponsive, with no pulse, and with agonal breathing (1343 hours). Dispatch was notified, cardiopulmonary resuscitation (CPR) and advanced life support were begun, an ambulance responded, and the Engineer was transported to the local hospital's Emergency Department. Inside the Emergency Department, advanced life support treatment continued with no improvement in the Engineer's condition. The attending physician pronounced the Engineer dead at 1427 hours and resuscitation efforts were discontinued. The death certificate and autopsy (completed by the Medical Examiner) listed "coronary artery heart disease" as the cause of death. The NIOSH investigator concluded that the physical stress of responding to three alarms and participating in vigorous exercise, coupled with the Engineer's underlying coronary artery disease, triggered his sudden cardiac death. The NIOSH investigator offers the following recommendation to prevent similar incidents: Ensure annual medical evaluations that include electrocardiograms (EKGs) and exercise stress tests are performed for fire fighters at risk for coronary artery disease. The following recommendation is made to enhance safety and health. It did not contribute to the Engineer's death. 1. Eliminate or reduce the frequency of periodic chest x-rays in asymptomatic fire fighters, unless clinically indicated.