On September 14, 2007, a 38-year-old male career Fire Fighter-Emergency Medical Technician (FF-EMT) responded to six calls during his shift, including a fire in an apartment building. At the apartment fire, the FF-EMT performed forcible entry at multiple locations throughout the building while wearing full turnout gear and self-contained breathing apparatus (SCBA). He was still sweating profusely after returning to the fire station. After resting for about 60 minutes, his engine company was dispatched to back-to-back calls involving an automobile accident and downed power lines. About 5½ hours later, the FF-EMT went to the engine bay to restore equipment in the medical bag. A short while later, the Lieutenant (LT) found the FF-EMT lying next to Engine 6. Assessment of the FF-EMT revealed he was unresponsive, not breathing, and pulseless. Crew members and an ambulance were alerted as the LT obtained the automated external defibrillator (AED) and oxygen bag from the Engine and began cardiopulmonary resuscitation (CPR). One shock was administered before the ambulance and paramedics arrived. Despite CPR and advanced life support administered onscene, during transport, and in the hospital's Emergency Department, the FF-EMT died. The death certificate (completed by the City Clerk) and the autopsy (completed by the State Chief Medical Examiner) listed "atherosclerotic cardiovascular disease" as the cause of death. The NIOSH investigator concludes the FF-EMT's underlying atherosclerotic coronary artery disease (CAD), coupled with his alarm responses and exertional activities at six calls (including a structure fire) triggered his sudden cardiac death. The NIOSH investigator offers the following recommendations to address general safety and health issues. It is possible these recommendations could have prevented the FF-EMT's sudden cardiac death at this time. 1. Conduct annual medical evaluations. 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. Provide fire fighters with medical clearance to wear self-contained breathing apparatus (SCBA) as part of the Fire Department's medical evaluation program. 5. Use a secondary (technological) test to confirm appropriate placement of the endotracheal tube. 6. Follow NFPA 1582 guidelines for when and how to restrict fire fighters with specific medical conditions.