On April 2, 2001, a 52-year-old male career Fire Fighter-Driver/Engineer (FF-D/E) was approaching the end of his 24-hour shift. At approximately 0645 hours, the FF-D/E reported nausea and epigastric/chest pain to awakening crewmembers. Alertly, these crewmembers immediately called dispatch for an ambulance, and then retrieved the automated external defibrillator (AED) and oxygen equipment from the Station's Engine. Oxygen was administered by mask as the initial evaluation revealed a conscious, ambulatory FF-D/E with a weak pulse. A few minutes later, as the ambulance arrived on-site, his condition worsened as the deceased began to have severe shortness of breath and diaphoresis (a cold sweat on the skin). As the paramedics began loading the FF-D/E into the back of the ambulance for transport, he lost consciousness and had a cardiac arrest. Cardiopulmonary resuscitation (CPR) was started and, enroute to the hospital, the paramedics were able to successfully shock (cardiovert) the FF-D/E back into a viable heart rhythm with the FF-D/E regaining consciousness. Unfortunately, as the FF-D/E arrived in the hospital's emergency department (ED), he again suffered cardiac arrest. Despite advanced life support (ALS) begun in the ambulance and continuing in the ED for 41 minutes, the FF-D/E died. The death certificate and autopsy report, completed by a forensic pathologist with the Medical Examiner's Office, listed acute myocardial infarction and coronary artery thrombosis due to atherosclerotic cardiovascular disease as the immediate cause of death. The following recommendations address some general health and safety issues. 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, or consensus votes of technical committees of the National Fire Protection Association (NFPA) or fire service labor/management groups. Sadly, it is unlikely any of these recommendations could have prevented the tragic and untimely death of this FF-D/E: 1. provide annual medical evaluations consistent with NFPA 1582; 2. consider performing exercise stress tests (EST) on select fire fighters; 3. negotiate with the local union to phase-in a mandatory fitness and wellness program consistent with NFPA 1583 and/or the Fire Service Joint Labor Management Wellness/Fitness Initiative; 4. negotiate with the local union to phase-in an annual physical ability test; 5. perform autopsies on fire service personnel consistent with U.S. Fire Administration and U.S. Department of Justice Public Safety Officer Benefits protocols; and, 6. expand access to critical incident stress counseling to members of the entire Fire Department.