On May 13, 2004, a 42 year-old male volunteer Fire Fighter (FF) suffered a cardiac arrest while battling a residential structure fire. He had engaged in hose pulling and exterior fire suppression activities for approximately 15 minutes. Shortly thereafter, fellow fire fighters reported that he "did not look right." On-scene Emergency Medical Service (EMS) personnel were summoned to assist the FF, only to find him at the back of the rescue truck in cardiac arrest. Cardiopulmonary resuscitation (CPR) was immediately begun. Once the on-scene ambulance relocated to the FF's vicinity, advanced life support (ALS) protocols were initiated and continued en route to the hospital. His condition failed to improve. Despite over 30 minutes of resuscitative efforts at the scene, in the ambulance, and at the hospital, the FF died. The death certificate completed by the medical examiner listed the immediate cause of death as an acute myocardial infarction (heart attack) with physical exertion in a hot, humid environment listed as a contributing cause. An autopsy was not performed. NIOSH investigators concluded that the FF's heavy physical exertion, coupled with his probable underlying coronary artery disease (CAD) triggered his sudden cardiac death. It is unlikely the following recommendations could have prevented the FF'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. Expand the current annual medical evaluation requirement to include Driver/Operators. 2. Consider conducting exercise stress tests (ESTs) for FFs with two or more coronary artery disease (CAD) risk factors. 3. Ensure FFs are cleared for duty by a physician knowledgeable about the physical demands of fire fighting and the various components of NFPA 1582, and ensure that the results of these exams are discussed with the FFs. 4. Phase in a mandatory wellness/fitness program for FFs to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 5. Conduct pre-placement and annual physical performance (physical ability) evaluations on FFs to ensure that they are physically capable of performing the essential job functions of structural fire fighting. 6. Strengthen the FD's current rehabilitation program. 7. Provide annual bloodborne pathogen (BBP) training to members likely to come into contact with blood while serving as a first responder. 8. Perform an autopsy on all on-duty fire fighter fatalities.