On May 13, 2004, a 28-year-old male volunteer Fire Chief was attending an emergency medical services (EMS) conference in another state. The first night after arriving at the training city, the Chief and his wife went to bed at 2230 hours. The next morning, at 0900 hours, the Chief's spouse awoke and found the Chief deceased. She called 911 and an ambulance responded. From the Chief's clinical condition, it was obvious he had expired some time earlier. Cardiopulmonary resuscitation (CPR) and advanced life support (ALS) treatment were not performed, and he was pronounced dead at the scene by the medical examiner. The death certificate and the autopsy, completed by the Chief Medical Examiner, listed "accidental multiple drug intoxication" as the cause of death. The NIOSH investigator's review supports this conclusion. NIOSH investigators offer the following recommendations to address general safety and health issues: 1. Provide pre-placement and annual medical evaluations to ALL fire fighters to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others. 2. Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA). 3. Phase in a MANDATORY wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 4. Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are physically capable of performing the essential job tasks of structural firefighting. 5. Ensure that fire fighters are cleared for duty by a physician knowledgeable about the physical demands of firefighting, the personal protective equipment used by fire fighters, and the various components of the National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments (FDs).