On April 27, 2007, a 51-year-old male career Captain and a crew member drove to another city to attend high-rise incident command training. After checking into the hotel, he and the crew member went to eat dinner (2230 hours). After eating and visiting with friends, the Captain complained of not feeling well and wanted to return to the hotel. Outside the restaurant, the Captain collapsed. The crew member assessed him and found him unresponsive, with agonal breathing, and with a slow pulse. The crew member began assisted ventilation via mouth-to-mouth resuscitation. An ambulance responded and provided advanced life support, including cardiopulmonary resuscitation (CPR). Approximately 47 minutes later, despite CPR and advanced life support administered on-scene and at the hospital, the Captain died. The death certificate and the autopsy (completed by the Assistant Medical Examiner) listed "hypertensive and atherosclerotic cardiovascular disease" as the cause of death. The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommendations been in place prior to 2007, perhaps the Captain's sudden cardiac death could have been prevented. 1. provide mandatory annual medical evaluations to fire fighters consistent with National Fire Protection Association (NFPA) 1582 to determine their medical ability to perform duties without presenting a significant risk to the safety and health of themselves or others. 2. Incorporate exercise stress tests into the Fire Department's medical evaluation program. 3. Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA) as part of the Fire Department's medical evaluation program. 4. Phase-in a comprehensive wellness and fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 5. Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are capable of performing the essential job tasks of structural firefighting. 6. Eliminate or reduce the frequency of periodic chest x-rays in asymptomatic fire fighters, unless clinically indicated.