On January 21, 2004, a 35-year-old male volunteer Captain responded to two alarms: a motor vehicle crash (MVC) with an injury, and a reported house fire that turned out to be a false alarm. Returning to the fire station after the false alarm, he complained of not feeling well and went home. After being home about 15 minutes, he collapsed. The Captain was transported to the local hospital and later flown to a regional hospital for diagnostic testing. Despite having a cardiac catheterization with coronary angiography, and a chest computed tomography (CT) scan, his aortic dissection went undiagnosed. He was treated for bilateral pneumonia but his condition continued to deteriorate. Despite cardiopulmonary resuscitation (CPR) and advanced life support (ALS), the Captain was pronounced dead approximately 20 hours after his initial complaint. The autopsy revealed the cause of death to be "hemopericardium" due to an "aortic rupture" and "aortic dissection." It is unlikely the following recommendations could have prevented the Captain's death. Nonetheless, the NIOSH investigators offer these recommendations to reduce the risk of on-the-job heart attacks and sudden cardiac arrest among fire fighters. 1. Provide mandatory pre-placement and annual medical evaluations to ALL fire fighters consistent with 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. Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are physically capable of performing the essential job tasks of structural fire fighting. 3. Phase in a mandatory wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 4. Ensure that fire fighters are cleared for duty 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 Comprehensive Occupational Medicine Program for Fire Departments. 5. Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA).