On February 12, 2001, a 60-year-old male volunteer fire fighter responded to a structural fire in a rural area. At about 2116 hours, about two minutes after arriving at the scene, he developed difficulty breathing after helping pull fire hose off the engine and straightening it on the ground. A crew member and the Chief advised him to sit down and await the ambulance that was also responding to the fire. The ambulance arrived about a minute later, the ill fire fighter walked to it, and the ambulance departed at 2128 for the nearest hospital, arriving at 2147 hours. En route, the fire fighter was treated with oxygen, aspirin, and nitroglycerin. He remained conscious, though in increasing respiratory distress, until he lost his pulse as the ambulance was approaching the hospital. Cardiopulmonary resuscitation (CPR) was begun in the ambulance, and after about six minutes of advanced life support (ALS) in the hospital emergency department, his heartbeat was restored. He was stabilized, and at 2300 hours he was evacuated by helicopter to a tertiary care hospital. He never regained consciousness, and neurological assessment indicated irreversible brain damage. On February 19, at the family's request, ventilatory support was discontinued, and the fire fighter died. Although a myocardial infarction (heart attack) was initially suspected, this was not supported by subsequent electrocardiographic findings or elevated blood levels of cardiac enzymes. The autopsy found arteriosclerosis of some of the arteries to the brain, and atherosclerotic coronary artery disease, but no coronary artery thrombosis or other signs of myocardial infarction. Autopsy findings indicated acute brain and spinal cord damage due to hypoxia/ischemia (lack of oxygen), apparently a result of the cardiac arrest. The autopsy documented congestive heart failure, and based on the clinical history and autopsy results, concluded that this, complicated by an arrhythmia (abnormality of heart rhythm), was the most likely cause of the acute illness at the fire scene. The death certificate, completed by the coroner of the deceased fire fighter's county, listed "Hypoxia / Ischemia, Acute [of the brain and spinal cord]" as the immediate cause of death, various autopsy findings as intermediate causes, and "Overexertion from responding to a fire call with Fire Dept" as the underlying cause. The following recommendations address some general health and safety issues identified during this investigation. This list includes some preventive measures that have been recommended by other agencies to reduce the risk of on-the-job heart attacks and sudden cardiac arrest among fire fighters. These selected recommendations have not been evaluated by NIOSH, but represent published research, consensus votes of technical committees of the National Fire Protection Association (NFPA), or fire service labor/management groups: 1. Institute pre-placement and periodic medical evaluations. These should incorporate exercise stress testing (EST), depending on the fire fighter's age and coronary artery disease (CAD) risk factors; 2. Fire fighters should be cleared for duty and for respirator use by a physician knowledgeable about the physical demands of fire fighting, the personal protective equipment used by fire fighters, and the various components of NFPA 1582, Standard on Medical Requirements for Fire Fighters and Information for Fire Department Physicians; and, 3. Phase in a mandatory wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity.