On February 19, 2007, a 44-year-old male career Fire Fighter-Emergency Medical Technician (FF-EMT) started his shift at 0800 hours. At 1642 hours, he responded to a fire in a high rise apartment building. When the FF-EMT arrived at the fire scene, he was assigned to perform a search for fire victims on the 6th floor. In full turnout gear and self-contained breathing apparatus (SCBA), he performed two walkthroughs looking for spot fires and conducting overhaul activities. The FF-EMT was about to make the third walkthrough when he commented to a crewmember that, "the stairs were a killer." He then turned around, took a few steps, and collapsed. The crew member thought the FF-EMT had tripped on hoselines and tried to assist him in getting up. When the FF-EMT did not respond, nearby crew members were alerted. Incident Command was notified. Initial crewmember assessment revealed the FF-EMT was unresponsive with labored breathing. Shortly thereafter, he lost his pulse and stopped breathing. Cardiopulmonary resuscitation (CPR) was begun, and paramedics (already on scene) responded to the 6th floor to begin treatment. Despite advanced life support treatment, including defibrillation and intubation, administered on-scene, during transport, and in the hospital's Emergency Department, the FF-EMT died. The death certificate (completed by the county coroner) and the autopsy (completed by a pathologist) listed "ischemic heart disease" as the cause of death. The NIOSH investigator concludes the FF-EMT's underlying atherosclerotic coronary artery disease (CAD), coupled with his heavy physical exertion activities at two structure fires triggered his sudden cardiac death. The NIOSH investigator offers the following recommendations to address general safety and health issues. It is possible that had the programs noted below been in place, the FF-EMT would have been on restricted duty until he was medically cleared for full firefighting duty, possibly preventing his sudden cardiac death. 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. Phase-in a comprehensive wellness and fitness program for fire fighters to reduce risk factors for cardiovascular disease and improve cardiovascular capacity. 3. Perform an annual physical performance (physical ability) evaluation to ensure fire fighters are physically capable of performing the essential job tasks of structural firefighting. 4. Secure endotracheal tubes to prevent dislodgment during patient treatment, transfer, and transport. 5. Reconsider routine use of coronary artery calcium scans.