On September 21, 2006, a 38-year-old volunteer fire fighter/emergency medical technician (EMT) arrived for training at his fire station at 1945 hours. The training scenario involved vehicle extrication with hydraulic rescue tools. After training for 2 hours, he left the fire station at about 2145 hours complaining of fatigue, which fellow crew members attributed to his 12-hour EMT shift immediately before the training. He returned home and showered. Just before going to bed, he told his roommate that he was experiencing an "aura." Shortly thereafter, he began exhibiting seizure activity. The emergency medical system was called and an ambulance arrived at 0016 hours. He was unresponsive with no pulse or respiration. He died even though he had received cardiopulmonary resuscitation (CPR) at home and advanced cardiac life support in the ambulance, the emergency department, and the intensive care unit of the hospital. The death certificate and autopsy, completed by the chief medical examiner, listed the immediate cause of death as "intramural coronary artery disease with severe fibromuscular dysplasia of the artery to the AV node of the heart following a volunteer fire training session." Other significant conditions contributing to death but not related to the given cause was "seizure disorder." The NIOSH investigator concurs with this conclusion. NIOSH investigators offer these recommendations to reduce the risk of on-duty sudden cardiac arrest among fire fighters: 1. Consider modifying the current medical evaluation program to be consistent with NFPA 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments; and, 2. Following an injury/illness, the final determination of a fire fighter's return-to-work status should be made by the fire department physician who is knowledgeable about the physical demands of fire fighting, the medical requirements of fire fighters, and the various components of NFPA 1582. Although unrelated to this fatality, the fire department should consider these additional recommendations: 1. Phase in a wellness/fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity; and, 2. Perform an annual physical performance (physical ability) evaluation for ALL fire fighters to ensure they are physically capable of performing the essential job tasks of structural fire fighting.