The tips are broken down into four steps: prepare, communicate, operate and compensate (PCOC), and checklists under each of these four categories outline dozens of steps clinics can take to help minimize treatment delays during a disaster. For example, checklists advise clinics to create emergency operations plans tailored to their unique circumstances; provide patients with access to their treatment plans via flash drives; identify alternative sources of power for radiation therapy machines; and delineate methods to keep in contact with patients, staff and other medical facilities during power and cell phone service outages.

The suggestions also include communication strategies such as working with local radio stations and newspapers to reach patients without internet service, as well as activating personal and family communication networks. In the wake of Hurricane Maria crisis, for instance, ASTRO created public service announcements designed to reach relatives and friends in mainland U.S. cities with high Puerto Rican populations, who could then pass information on to family and friends in Puerto Rico.

The paper’s extensive guidance covers a wide range of strategies, many of which might seem unnecessary on the mainland. But, the authors note, nobody ever thought they’d be necessary in Puerto Rico, either. “This was above and beyond what anybody could imagine,” said Dr. Gay.

“Although a near-total disruption of services is unlikely in the mainland U.S., a similar degree of cascading local or regional dysfunction is indeed possible consequent to hurricanes or other calamities that disrupt the electric power grid, water supply, transportation systems or distribution networks for food, medicine and other critical supplies,” the authors wrote. “The experiences of Hurricane Maria in Puerto Rico (2017), Hurricane Katrina in New Orleans (2005), and Hurricane Andrew in South Florida (1992) provide lessons that can inform preparations to increase resiliency when facing the most probable risks in any locale.”

In some ways, clinics in Puerto Rico were better prepared than clinics in the mainland United States – such as having diesel generators on hand to provide temporary power, said Dr. Gay. The Puerto Rico clinics lacked sufficient fuel to power lights and machinery for long periods of time, however, and had no easy way of replenishing those supplies. Nor could they easily transfer patients to another clinic, as might be possible on the mainland.

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