On October 24, 2005, the Lieutenant (LT) arrived for duty at his fire station at 0700 hours. Throughout the morning the crew checked the fire apparatus and equipment, then performed station housework (cleaning, sweeping, mopping, etc.). During the day, the crew responded to four incidents: two fire alarms and two EMS calls. During all four responses, the LT performed only light physical activity. Later that evening, while sitting in a chair, the LT collapsed. Despite exhaustive cardiopulmonary resuscitation (CPR) performed at the scene, in the ambulance, and in the emergency department (ED) of the local hospital, the LT died. The autopsy, completed by the medical examiner, revealed marked enlargement of the heart with left ventricular hypertrophy. The death certificate, also completed by the medical examiner, listed cardiac arrhythmia as the immediate cause of death due to hypertensive cardiovascular disease. The NIOSH investigator concluded the LT's underlying heart disease, possibly triggered by the stress of responding to two emergency calls earlier in the day caused his sudden cardiac death (SCD). His death may have been avoided at this time if the fire department (FD) followed National Fire Protection Association (NFP A) 1582, Standard on Comprehensive Occupational Medicine Program for Fire Departments. NIOSH investigators also concluded that to minimize the risk of similar occurrences, the FD should: 1. Provide 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. 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. 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 fire fighting. Although unrelated to this fatality, the Fire Department should consider this additional recommendation based on health and economic considerations: 1. Discontinue lumbar spine x-rays as a screening test administered during the pre-placement medical evaluation.