On October 13, 2000, a 63-year-old male Driver/Operator (D/O) responded to three emergency incidents. The second incident was a motor vehicle crash involving a tractor-trailer; the victim, wearing full bunker gear, assisted in spreading 50 bags of absorbent to prevent the leaking fuel from entering the sewer system. After being on the scene for over 2 hours, the victim mentioned to crew members that he was experiencing shoulder pain. Later that evening, the victim was found in his bunk unresponsive, not breathing, and pulseless. Despite cardiopulmonary resuscitation (CPR) and advanced life support (ALS) administered by the fire fighters, ambulance emergency medical technicians (EMTs) and paramedics, and by hospital personnel in the emergency department (ED), the Driver/Operator died. The death certificate, completed by the emergency department physician, listed cerebral event as the immediate cause of death, due to cerebral hypoperfusion and coronary artery disease. No blood tests were done and no autopsy was performed. Other agencies have proposed a three-pronged strategy for reducing the risk of on-duty sudden death and sudden cardiac death among fire fighters. This strategy consists of (1) reducing physical stress on fire fighters (2) screening to identify and subsequently rehabilitate high risk individuals and (3) encouraging increased individual physical capacity. Issues relevant to this Fire Department include: 1. Fire Fighters should have mandatory annual medical evaluations and periodic physical examinations to determine their medical ability to perform duties without presenting significant risk to the safety and health of themselves or others; 2. Exercise stress tests should be incorporated into the Fire Department's medical evaluation program; 3. Fire fighters should be cleared for duty by a physician knowledgeable about the physical demands of fire fighting and the various components of NFPA 1582; and, 4. A mandatory wellness/fitness program for fire fighters should be phased in to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. Additional recommendations include: 1. Autopsies should be performed on all on-duty fire fighters whose death may be cardiovascular-related; and, 2. Adequate fire fighter staffing should be provided to ensure safe operating conditions.