On April 15, 2004, a 57-year-old male career Acting Fire Chief worked his normal 10-hour shift, during which he participated in union negotiations. Throughout the day, he complained of not feeling well, and, after going home, his symptoms worsened. He telephoned his fire station and requested transport to the hospital. Thirty-eight minutes later, as the ambulance arrived at the hospital’s emergency department (ED), he suffered cardiac arrest. Despite advanced life support (ALS) performed by ambulance service emergency medical technicians (EMTs) and paramedics and hospital emergency department (ED) personnel, he died. The death certificate listed “cardiac event” as the immediate cause of death. No autopsy was performed. The NIOSH investigator concluded that a heart attack was the most likely cause of death.