If you’ve spent any time reading about medical ethics or disaster preparedness, you might have stumbled upon the term "Texas Score." It sounds like something out of a sports broadcast or maybe a high-stakes poker game. It’s not. In reality, it is a sober, calculated method used by healthcare professionals to make impossible decisions when resources—like ventilators or ICU beds—simply run out.
Honestly, it’s a heavy topic.
The Texas Score is essentially a triage framework. It was designed to help doctors decide who gets life-saving treatment during a public health emergency. Think back to the height of the COVID-19 pandemic. Hospitals were overflowing. Staff were exhausted. In those moments, you can’t just rely on "first come, first served." That would be a disaster. Instead, medical boards in Texas developed a specific scoring system to prioritize patients based on their likelihood of survival.
What is the Texas Score exactly?
At its core, the Texas Score (often officially referred to as the Texas Triage Score or part of the Texas Disaster Medical System protocols) is a point-based system. It uses clinical data to predict short-term mortality. The goal is simple but brutal: save the most lives possible with the limited tools available.
It’s not about who is "more important" or who has better insurance. It’s about biology. The system primarily looks at a patient's current physiological state. Most versions of these protocols lean heavily on the SOFA score (Sequential Organ Failure Assessment). This isn't just a Texas thing—SOFA is used globally—but the way Texas integrated it into their specific state-wide disaster protocols is what gave it its name in common parlance.
Doctors look at six different organ systems:
- Respiratory (lungs/oxygen levels)
- Cardiovascular (blood pressure and need for medication to keep the heart pumping)
- Hepatic (liver function)
- Coagulation (how well the blood clots)
- Renal (kidneys)
- Neurological (Glasgow Coma Scale)
Each system gets a score from 0 to 4. A higher score means more severe organ failure. When you add them up, you get a number that tells a story about how likely that person is to walk out of the hospital.
Why people get the Texas Score wrong
There is a massive amount of misinformation floating around about this. Some people think it’s a way to "weed out" the elderly or people with disabilities. That’s a scary thought, but it’s not how the ethics committees actually wrote the rules.
In fact, federal civil rights laws—and specifically guidance from the Office for Civil Rights (OCR) at the Department of Health and Human Services—prohibit triage scores from being based solely on age or disability. If a hospital tried to use the Texas Score to say "everyone over 80 gets zero help," they’d be in massive legal trouble.
Instead, the score is dynamic. It changes. A patient might start with a "good" score, but if their organs begin to fail over the next 48 hours, their score goes up. This tells the triage team that the treatment isn't working as well as hoped. It’s a constant, agonizing re-evaluation.
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The ethical tightrope of "Saving the Most Lives"
The philosophy behind the Texas Score is utilitarian. That’s a fancy way of saying "the greatest good for the greatest number."
In normal times, doctors do everything for the patient in front of them. It’s the "duty of care." But in a crisis—a "Crisis Standard of Care"—the duty shifts from the individual to the entire population. It’s a total flip in medical logic.
Imagine you have one ventilator and two patients. Patient A is 45 years old with a Texas Score of 2 (meaning mild organ dysfunction). Patient B is 45 years old with a Texas Score of 14 (meaning multi-organ failure and a very low chance of survival even with the machine). Under these protocols, the ventilator goes to Patient A.
It feels cold. It is cold. But the alternative is choosing randomly, which could result in both patients dying if the one who got the machine was too sick to ever recover anyway.
Specifics of the scoring metrics
We should get into the weeds for a second because the details matter. When a doctor calculates a Texas Score, they aren't just guessing. They are looking at lab results.
For the liver, they check bilirubin levels. For the kidneys, they check creatinine. They look at the "Mean Arterial Pressure" to see if the heart is struggling. These are hard numbers.
The interesting part of the Texas approach—unlike some other states—is how they handle "tie-breakers." If two people have the exact same clinical score and there is only one bed, what happens? Some versions of the protocol suggest a lottery. Others look at "life cycles"—prioritizing those who haven't had the chance to live through various stages of life (childhood, young adulthood). This is where the debate gets really heated.
The role of the Triage Officer
One of the most important parts of the Texas system is that the doctor treating you is usually not the one calculating your score.
This is a huge deal.
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The "Triage Officer" or "Triage Committee" is a separate group of experts. They look at the data without names or faces attached to it whenever possible. This prevents "bedside bias." Your doctor stays your advocate. They keep fighting for you. The Triage Officer is the one looking at the big picture of the whole hospital. This separation is meant to protect the mental health of the bedside doctors and ensure fairness for the patients.
Real-world application: Was it used during COVID-19?
This is where things get blurry. Technically, many hospitals in Texas activated their surge protocols, but few officially declared "Crisis Standards of Care" where they were forced to deny care based strictly on the Texas Score.
However, "soft triage" happened everywhere. Doctors had to make tough calls about who got moved to the ICU and who stayed in the ER. They used the principles of the score even if they didn't fill out the official paperwork every single time.
Dr. John Hick, a national expert on triage, has often noted that the transition from "contingency" care to "crisis" care is a sliding scale. You don't just wake up and decide to use a scoring system; you start using it when you realize that if you don't, the whole system will collapse.
Addressing the disability rights concerns
Groups like Disability Rights Texas have been very vocal about these scores. They argue that "subjective" measures—like the Glasgow Coma Scale—might unfairly penalize people with pre-existing neurological conditions.
Because of this pressure, the guidelines have been refined. Modern versions of the Texas Score protocols explicitly state that clinicians must account for a patient’s baseline. If someone has a permanent physical disability that doesn't affect their chance of surviving the current acute illness, that disability shouldn't make their score worse. It’s a delicate balance that the state is still trying to perfect.
How to understand your own "Risk"
People often ask: "What can I do to ensure I have a good score?"
The reality is that you can’t "game" the Texas Score. It is a reflection of how sick you are in a specific moment of crisis. However, having a clear Advanced Directive or Medical Power of Attorney is the best way to maintain control. If the score indicates a low chance of survival, your Advanced Directive tells the doctors what you want—whether that’s "do everything" or "let me go comfortably."
Future of Triage in Texas
The Texas Score isn't a static document. It’s constantly being reviewed by the Texas Medical Board and the Department of State Health Services. They look at data from past surges to see if the scores actually predicted survival correctly.
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If the data shows that people with a certain score survived at higher rates than expected, the point values get adjusted. It’s a scientific process aimed at reducing the margin of error in what is arguably the most stressful calculation a human being can make.
Actionable insights for the public
Understanding the Texas Score isn't about fear; it’s about being informed. Here is what you actually need to do with this information:
Update your medical records. Ensure your primary care physician has an accurate list of your baseline health conditions. This prevents a Triage Officer from misinterpreting a chronic condition as an acute organ failure during a crisis.
Designate a Medical Power of Attorney. In a situation where triage scores are being used, you might not be able to speak for yourself. You need someone who knows your wishes and can communicate with the hospital's ethics committee if necessary.
Understand the "SOFA" basics. If a loved one is in the ICU, ask the doctors about their "SOFA trends." If the score is going down, it’s a sign of recovery. If it’s climbing, it’s a sign that the body is struggling to respond to treatment.
Advocate for transparency. If you are in a hospital during a declared emergency, you have the right to ask if Crisis Standards of Care are in effect. Awareness of the "rules of the game" allows families to make more informed decisions about palliative care versus aggressive intervention.
Don't panic over "Death Panel" rhetoric. These scores are built on clinical data, not political whims. They are a last resort, meant to prevent total chaos when a hospital is literally at its breaking point.
The Texas Score remains a controversial but necessary tool in the world of emergency medicine. It represents the intersection of math, medicine, and morality. While we hope it never has to be used at full scale again, its existence ensures that if the worst happens, there is a fair, transparent framework in place to save as many people as possible.