On April 12, 2008, a 65-year-old male volunteer Fire Chief was dispatched to a structure fire. On scene, he discussed fire suppression tactics with the Assistant Chief and assisted with stretching an uncharged 1¾-inch hoseline. The Chief then stated to the Assistant Chief that he "could not catch his breath." After sitting down for about 5 minutes, the Chief requested an ambulance. Deciding not to wait for the ambulance to arrive, the Chief asked the police officer directing traffic around the incident to take him to the hospital. The Chief walked into the hospital's emergency department saying he was having breathing difficulty. Approximately 20 minutes later, the Chief went into cardiac arrest. Despite advanced life support in the emergency room for 35 minutes, the Chief died. The death certificate, completed by the coroner, listed "acute myocardial infarction due to stress" as the cause of death. The autopsy, completed by the pathologist, listed "severe hypertensive heart disease" as the cause of death with "moderate multiple vessel coronary artery disease" as an underlying condition. NIOSH investigators conclude that responding to the fire and the physical stress of stretching the fire hose, given the Chief's underlying heart condition, triggered a cardiac arrhythmia, resulting in his sudden cardiac death. The NIOSH investigator offers the following recommendations to address general safety and health issues. Had these recommended measures been in place prior to the Chief's collapse, his sudden cardiac death may have been prevented. 1. Provide preplacement and annual medical evaluations to fire fighters consistent with National Fire Protection Association (NFPA) 1582, Standard on Comprehensive Occupational Medical Program for Fire Departments. 2. Ensure fire fighters are cleared for return to duty by a physician knowledgeable about the physical demands of fire fighting, the personal protective equipment used by fire fighters, and the various components of NFPA 1582.3. Phase in a comprehensive wellness and fitness program for fire fighters. 4. Perform an annual physical performance (physical ability) evaluation. 5. Provide fire fighters with medical clearance to wear self-contained breathing apparatus as part of the Fire Department's annual medical evaluation program.