A 34-year old male volunteer Fire Fighter Trainee attended a 3 month fire fighter certification course at the Regional Fire Academy. On August 14, 2007, the Trainee participated in a simulated fire suppression exercise consisting of rotating fire attack positions and maneuvering a 1-3/4-inch charged hoseline for about 30 minutes. After the exercise, participants returned to the classroom. Upon entering the classroom, the Trainee leaned against the wall, complained of chest pain, and collapsed. 9-1-1 was called as vital signs were taken, revealing a blood pressure of 70 millimeters of mercury (mmHg) systolic and a heart rate of 170 beats per minute. Despite supportive measures in the field and en route to the hospital, the Trainee remained in a semi-conscious state, with low blood pressure, and a fast heart rate. Inside the hospital's Emergency Department, an electrocardiogram (EKG) showed the Trainee was suffering from a heart attack and a cardiac arrhythmia (atrial fibrillation with rapid ventricular response). He underwent emergent cardiac catheterization which revealed an acute thrombus completely occluding his left main coronary artery. A stent was placed, but the Trainee went into cardiogenic shock which required prolonged resuscitation measures that resulted in anoxic brain damage. Two days later, the Trainee was declared brain dead by a consulting neurologist. After consultation with the family, the Trainee was taken off life support systems and died. The autopsy report listed the cause of death as "Acute myocardial infarction with systemic multi-organ effects of severe hypotension." NIOSH investigators agree with these reports, and that the heart attack was probably triggered by the moderate to severe physical exertion associated with the Trainee's simulated fire suppression training. The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommendations been in place, perhaps the Trainee's sudden cardiac death could have been prevented at this time. 1. Provide mandatory pre-placement and annual medical evaluations to fire fighters consistent with National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments, to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others. 2. Ensure fire fighters are cleared for duty by a physician knowledgeable about the physical demands of firefighting, the personal protective equipment used by fire fighters, and the various components of NFPA 1582. 3. Perform a candidate and an annual physical performance (physical ability) evaluation to ensure fire fighters are capable of performing the essential job tasks of structural firefighting. 4. Phase-in a comprehensive wellness and fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 5. Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA) as part of the Fire Department's medical evaluation program.