On June 22, 2007, a 56-year-old male volunteer Engineer was paged to a residential fire. He responded to a nearby fire station and drove an engine to the scene. On-scene, he assisted crew members in pulling an uncharged 1¾-inch hoseline. The fire was extinguished shortly thereafter, and the Engineer notified the Fire Marshal that he did not feel well and that his chest hurt. Assessment provided in the rehabilitation (rehab) unit by the on-scene ambulance crew revealed the Engineer was suffering from a heart attack (myocardial infarction). Despite advanced life support treatment initiated in rehab, the Engineer became unresponsive with labored breathing. As the ambulance began transport to the hospital's Emergency Department, the Engineer lost his pulse and stopped breathing. Cardiopulmonary resuscitation (CPR) was begun and advanced life support treatment continued en route to the hospital. Approximately 55 minutes after his collapse, despite CPR and advanced life support administered on-scene and at the hospital, the Engineer died. The death certificate, completed by the medical examiner, listed "myocardial infarction" as the cause of death. No autopsy was conducted. The NIOSH investigator concludes the Engineer's response to the structure fire and his exertional activity at the fire, coupled with his underlying atherosclerotic coronary artery disease (CAD), triggered his heart attack and sudden cardiac death. The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommended measures been in place prior to the Engineer's collapse, perhaps his sudden cardiac death could have been prevented at this time. 1. Provide 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. Incorporate exercise stress tests following standard medical guidelines into the Fire Department's medical evaluation program. 3. Secure endotracheal tubes to prevent dislodgment during patient treatment, transfer, and transport. 4. Phase-in a comprehensive wellness and fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 5. Perform an autopsy on all on-duty fire fighter fatalities.