On July 6th and 7th, 2005, a 54-year-old male career Fire Apparatus Operator (FAO) responded to 12 calls, 10 of which resulted from a tropical storm. Four calls involved removing tree limbs from the roadway. As he returned to the station after the last call, the FAO collapsed inside the cab of the engine. An ambulance was requested as crew members assessed the FAO and began cardiopulmonary resuscitation (CPR) and advanced life support (ALS) treatment. The ambulance transported the FAO to the hospital's emergency department where CPR and ALS treatment continued for an additional 24 minutes. Despite this treatment, the FAO died. The death certificate and the autopsy, completed by the County Medical Examiner, listed "cardiac dysrhythmia due to atherosclerotic coronary artery disease (CAD)" as the cause of death. The NIOSH investigator concluded that the physical stress of responding to 12 calls, including tree limb removal, and the presence of his underlying atherosclerotic cardiovascular disease probably contributed to the FAO's sudden cardiac death. NIOSH investigators offer the following recommendations to prevent similar incidents and to address general safety and health issues: 1. Perform pre-placement and periodic medical evaluations consistent with NFPA 1582 guidelines. 2. 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) Standard 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. 3. Perform symptom-limiting exercise stress tests on members at high risk for CAD. 4. Provide fire fighters with medical evaluations and clearance to wear self-contained breathing apparatus (SCBAs). 6. Develop a structured wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity.