Despite the promise and universal use of the Kouwenhoven technique for closed chest cardiac massage, this method has been shown repeatedly to suffer from lack of clinical efficacy. Although the Kouwenhoven technique can clearly save lives, the inherent inefficiency of this approach and the challenges related to teaching and retaining the skills needed to perform the technique correctly have limited its overall effectiveness. This has prompted the development of newer lifesaving CPR techniques and devices. Some of the advances, such as the vest approach, active compression-decompression, and the impedance threshold valve, offer a benefit when compared with the Kouwenhoven technique. It is clear, however, that challenges related to implementation of these newer approaches will determine their ultimate utility. It is not sufficient to have a better technique or device available. Challenges to implementation of the newer approaches include overcoming the inertia of a universal mindset on the already-familiar Kouwenhoven technique and creating a cost-effective justification for change. Each year, approximately 10 million people in the United States are trained in the Kouwenhoven technique. Americans spend nearly $500,000,000 annually on this form of CPR training and retraining. Given the less than 5% survival rate for the 300,000 patients who experience out-of-hospital cardiac arrest each year in the United States, the prudence of this societal investment when compared with other ways health care dollars are spent should be questioned. It is hoped that this mismatch between costs and benefits will be recognized and will lead to the adoption of more effective means to resuscitate patients.