Cardiopulmonary Resuscitation has been studied and analyzed for years. Healthcare has different modalities for compressions, respirations, medications and we still have similar out of hospital cardiac arrest save rates as we did decades ago. The University of Texas Health San Antonio Emergency Health Sciences Office of the Medical Director (OMD) physicians and clinical training officers sat down, last Fall, to discuss the current state of CPR training. We were not satisfied. The OMD wanted to address the next level of CPR and resuscitation and developed their own CPR program. UTHSCSA applied to the State of Texas, to provide its own brand of CPR training and recertification, called the Orange Card, and in doing so developed the first agency-specific CPR program in Texas and maybe the nation. This addresses CPR from the perspective of best practice per UTHSCSA / SAFD and applies this best practice to our citizens. This includes video telemedicine in dispatch, utilizing the latest prehospital civilian/responder alert applications, and an ECMO CPR alert. This allows the San Antonio Fire Department to provide an individualized level of CPR resulting in enhanced provider capabilities and the latest resuscitation practices for the citizens of San Antonio.