Part One

I had to have a hard talk with a patient yesterday, about the fact that he has dementia, and can no longer trust what he “knows.” He’s been angry, paranoid, and difficult his entire admission; the only way his brain could rationalize the things happening to him was to assume the people around him had all turned on him and were conspiring against him. The day before, on my orders, security had to forcibly put him back in his room when he tried to leave. Yesterday he was calmer, but still angry and thinking nobody was taking him seriously.

Later in the day I caught him in a receptive moment, or perhaps the medications I had to have forcibly administered the day before were having some delayed effect, and so I broached the dementia subject. I frankly expected another verbal/physical explosion, but instead he sat quietly and soberly in his bed and told me about the research he had done when he was given the diagnosis, and how hard it had been for him to face the future he knew was coming. I ordered cognitive testing for today. I don’t know if he will still remember our conversation by the time it has been done, but at the time, we agreed it would give him a better idea of whether to believe himself or everyone else in the current situation, and whether his insistence on going home to his (terrorized and terrified) wife has merit, or if he should perhaps consider moving into a memory care facility. He said it would be hard for him, knowing he has slipped as much as I think he probably has, but he would rather know than not know.

I can not begin to imagine how it must feel to be a highly intelligent person whose mind is slowly slipping away like last night’s dream; to have some part of yourself still intact enough to be aware of the loss, while the rest of you is feeling indignant at being treated like a crazy person. It reminds me of how I felt during the first real earthquake I experienced as an adult, and the horribly disconcerting realization that absolutely EVERYTHING I had ever depended on to be solid and supportive and dependable was betraying me, and there was nothing to hold on to, nowhere to run, nothing firm or solid or immovable anywhere in my universe.

Part Two

A few weeks later, the same patient was back in the hospital. In just that short amount of time, his cognitive decline had progressed past that “tipping point” of awareness. Now, instead of frightened and angry over what he could see slipping away from him, he had forgotten that he had ever had it at all. 

He was no longer paranoid and upset. The fear and anger was gone. In its place was kind of a mild bafflement. He sat quietly in his room, calm and serene, looking contentedly out the window, interacting pleasantly with the staff who were caring for him. When I talked to him, he told me he was working on a paper he wanted to publish. He described, at great length, the theories he was developing for classifying human emotions according to a biological taxonomic system of phylums and families.

As our conversation drew to a close, he said, “I’m sorry…I’ve forgotten your name.” He looked apologetic, explaining, “I have dementia, you know.”

“I know,” I said, “it’s okay. My name is Ruth.” His eyes took on a far away look. “Ruth,” he said contemplatively, looking off into the distance somewhere over my left shoulder. “Ruth…” he said again. “…You know, I met someone named Ruth, one time. She was tall and slender, just like you…” He gazed into space for a moment more, trying to remember, then shook his head and shrugged as the ghost of a memory drifted away. He smiled, lifting a hand in farewell, as I retreated before he could see my tears.

Patient: Yeah, I’m trying to comprehend the evilness of divinity.

Me: Sorry, that’s outside my scope of practice.

I spent a great deal of time over the past 10 years digging into the issues with our health care system. It was not entirely voluntary, so don’t start thinking I’m some kind of super-duper truth-seeking zealot. I was in school for much of that time, and the health care system is, not surprisingly, a pretty important thing to know about when you’re in a health care profession, and I had to do a lot of analyzing and writing about all of this stuff in order to graduate, and convince my master’s committee I had achieved the level of knowledge and expertise required in order to be awarded my degree. As a result, I got pretty intimately acquainted with what the problems are and where we were headed, and why things needed to change, radically, if we wanted the system to stay around much longer. I read the original proposed healthcare bill in its entirety, and let me tell you, that was NOT fun. I waded through pages and pages of congressional testimony, and mountains of data, and…well, just take my word for it. You’re about to profit from years of mental pain and anguish on my part, at absolutely no charge. You’re welcome.

Along the way, both during my years in school and since entering the health care work force full time, I’ve also spent a lot of time getting up close and personal with the issues affecting our uninsured population, the barriers they face, and the impact that not having access to adequate health care has on them, their lives, and the rest of us. And I’ve had to let go of a whole lifetime of erroneous thinking and preconceived notions.

Before any of that happened, however, I lost a 6-figure job to the tech industry crash, and got an intense first-hand crash-course education in just exactly how little difference there really is between any of us and those people standing on street corners with cardboard signs. We were frighteningly close to ending up there ourselves, for a while. At the same time that we were trying to figure out how to keep one step ahead of having to fight for a spot to sleep under an overpass somewhere and scrounge up a piece of cardboard for our own panhandling sign, I also had to face the sudden and very uncomfortable realization that I had done a lot of judging in the past, toward people whose lives and circumstances I had made a lot of assumptions about but that it turned out I knew absolutely nothing about. I had, like so many others who have lived lives blessedly free of real hardship, the stupid notion that I somehow deserved my comfortable middle-class upbringing, when I really did nothing at all to earn it. It was just a random coin toss of fate that let me be born into the family I was born into, rather than into a poor, lower-class family where I would not have had the opportunities life had given me. I was no better or more deserving than the homeless guy on the corner. I had just been more lucky. But that’s a whole ‘nother story that’s already been documented elsewhere. Finish reading this one, for now, and then if you’re interested, I’ll give you the link to the other one. There’s even a movie to go with it. For real!

Anyway, here is a very simplified (as much as I can, anyway) explanation of why ACA (“ObamaCare”) was implemented and why is is absolutely essential that it go forward, and why it is actually a GOOD thing for our country and for us as individuals:

Since EMTALA, the law that says emergency care must be provided regardless of ability to pay, was enacted, but with no provision for funding it, medical costs have skyrocketed. Hospitals have to eat those unpaid bills. In order to stay afloat, that means they have to charge everyone else more to cover the costs they have to absorb. And emergency department things are much more expensive than things elsewhere in the hospital, so everything ends up costing a whole bunch more in order to make sure the hospital can afford to keep operating.

Also, when someone doesn’t have access to health care except via the ED, that means they can’t just go on in when they start to notice a problem. They have to wait until it’s bad enough to actually be considered an emergency. So, for example, instead of having their diabetes diagnosed early enough to treat it and keep it from progressing, they end up in the ED with a gangrenous foot ulcer that results in weeks in the hospital, possibly culminating in an amputation, then months of rehab, followed by disability, because now they have lost their leg and can’t work. And all of the costs for all those weeks/months of hospitalization, surgery, and care gets eaten by the hospital. Oh, they’ll bill the poor newly disabled person, of course, and the person will end up having to go bankrupt, and now their health is gone, their leg is gone, their job is gone, and so is their home, if they had one, and everything else.

Oh, yeah. All those millions of uninsured Americans out there? Over 2/3 of them are hard working people with full-time jobs, not the deadbeat freeloaders your far-right political leaders would like you to think they are. The disabled unemployed ones you probably picture when you think of “uninsured” are actually quite likely to already be covered by Medicaid. So take a moment to try and readjust the mistaken impression you’ve had so carefully implanted in your brain.

Got it? Okay. Let’s continue:

Let’s go back to the skyrocketing medical costs for a moment. They’re the highest in the world, by a huge margin, despite pretty mediocre results when you look at markers of population health. It’s a pretty sad state of affairs. Our infant mortality rate, one of the primary measures of the quality of a nation’s health care, is abysmal. Even some third world countries have better infant survival rates than we do.

Despite the huge inflation of medical costs in order to try to cover all the unpaid stuff, and cutting back staff so much that it impacts quality of care and threatens patient safety, a scary percentage per capita of hospitals have closed their doors over the past 20 years. I won’t try to quote the statistics, because I’m not sure I remember them correctly now, but it’s pretty staggering. An even larger percentage of emergency departments have shut down, since if a hospital doesn’t have an ED, they aren’t subject to EMTALA. Often, though, by the time they resort to such extreme measures it’s already too late, and the hospital goes under anyway. The most realistic projections, based on the rates of increasing medical costs, the economy, the increasing numbers of uninsured Americans and chronic illnesses, and the rate of hospital closures, are that we’d probably lose our last emergency department by the year 2020. And most of our hospitals.

That’s scary, boys and girls. Because no matter HOW rich you are, and no matter how stellar your health care insurance plan may be, if there’s nowhere for you to go for medical care when you have a massive heart attack in the middle of the night, you ARE going to die, and all your money won’t do you a bit of good.

Okay, try to stay with me. I’ve simplified this as much as I can, but there are still a lot of contributing factors you have to comprehend in order to get it.

Higher medical costs result in higher insurance costs. We all know how insurance works. It’s based on a very informed statistical prediction of what the likelihood is of a thing actually happening. Some of us pay homeowner’s insurance for years, for example, and never have anything happen that the insurance company has to cough up for. And, unless you’re fabulously wealthy and can afford to pay cash for your home, you are required to buy homeowner’s insurance in order to get a mortgage loan. So the insurance company is able to stay in existence and make a profit because they are collecting insurance premiums from far more people than they’re having to pay out on.

With medical insurance, however, there’s traditionally been little incentive to pay for it if you are a healthy person, and the more expensive it gets, the fewer people can afford it, until pretty much the only people who have it are the sick people, who are actually going to USE it. That makes medical insurance a risky business. For the insurance companies to stay afloat, they have to find ways to collect more money than they pay out. They’ve had to charge even higher premiums, as well as find any excuse they could NOT to pay as many claims as possible. Which, naturally, has not made them very popular, except with the book and movie industries who’ve profited from the resulting drama potential.

Here’s another important issue: Since our country has traditionally relied on employer-based healthcare, it impacts our industry, and our nation’s economy, too. (And this part I’ve oversimplified to a degree that borders on criminal, because economics hurts my brain.) It’s more and more expensive to employ Americans, because it costs so much to insure them, and that makes our goods and services more expensive, and makes it harder to compete in the world market. That’s why many companies have taken to moving their manufacturing overseas. Here’s a thing that really surprised me, though: if you looked at a graph of corporate and individual income levels over the past few decades, you’d notice that for the most part corporate profits have continued to rise pretty much at the same rate as they always have. Cost of living has also continued to increase. Individual income, however, which used to keep pace with the rise of corporate profits (and for reasons I have trouble comprehending, is supposed to do so, to keep the economy healthy), has flatlined. Are you getting that? Corporations are still making money and getting richer. Individuals, however, are getting poorer, because a dollar in today’s economy is not worth as much as a dollar was a few years ago. So when our salaries don’t increase, but everything else does, we’re actually getting poorer, even though we’re the ones making it possible for the corporations to get richer.

So why is this happening?

Well, employers aren’t going to give up their profits to cover the ever-increasing cost of providing healthcare. Sorry to break this to you, but your employer really doesn’t love you. You are a commodity. If they have a choice between making themselves poorer or making you poorer, guess who’s going to get poorer? So the way they pay for the increasing cost of providing you with employer-based healthcare is by continuing to pay you the same salary, instead of giving you the periodic increases you should have gotten to match the company’s growth. Companies keep getting richer, while their employees keep getting poorer as the cost of living goes up and their salaries don’t. That healthcare your employers have been “providing” you, you’ve really been paying for yourself. Part of the cost is deducted from your existing paycheck. That’s the part you can see, but it’s not really all you’re paying; it’s only a fraction. The rest comes in the form of the paychecks you might have gotten, if medical costs and therefore insurance costs hadn’t increased so much more rapidly than everything else.

But Americans don’t realize this is happening, because Americans only believe what they can see. And the raises they aren’t getting are invisible to them, so they just don’t exist, even though from an economic standpoint, they really do.

Stop again for a moment, because you need to let that sink in. Your money is being taken from you before you even get it, and diverted to pay for the cost of health care for the millions of uninsured people in this country. It’s like in the old west, when the bandits would rob the stagecoach before it got to the bank. That money belongs to you; you just don’t know it yet. And they think what you don’t know won’t hurt you, but it’s hurting all of us.

A few years back there was an experimental project in California that put some hard numbers to the difference between providing emergency care or primary care. This project focused on the homeless population, because they tend to be one of the most expensive populations for hospitals to provide medical care for. On average, it costs us (in that invisible money that gets stolen from us before we get to even enjoy the thought of getting it) $100,000 per homeless individual per year. So this one hospital identified their most expensive “frequent flyer” homeless emergency department patrons. They provided them with housing, food, and basic primary medical care. And then at the end of a year (it may have been longer; the details are fuzzy now) they took an accounting. I can’t remember the final per-person cost for certain now; I want to say it was like $12,000, but just to be safe, let’s call it “under $20,000.” They went from paying more than $100,000 in medical care for each of these individuals to paying only $20,000 (or less) per year, and that was for not just their medical care, but also their housing and food.

Okay. So if I came along and told you that you were going to have to do your part in making sure everyone in this country has health care, but I gave you a choice: You can have the equivalent of $100 per paycheck deducted from your annual salary before you ever see it, or you can have $20 per paycheck deducted and shown on your paystub, which would you choose? Seriously, if you would actually prefer the $100 option, email me, because I’ve got this bridge I’d love to sell you…

Are you getting the picture yet? ACA doesn’t mean we’re going to START paying for other people’s health care. ACA means we’re finally going to get to reduce what we’re paying to a much more reasonable amount, AND get better health care coverage for all of us in the bargain. Well, all of us who don’t live in states whose governors turned down the Medicaid expansion, that is. But that’s another post, and plenty of people have already written that one, so I’ll get back to the one I’m writing…

So, along comes ACA, with a way to shift the costs. If everyone is insured, then there’s more money available for insurance companies to pay for medical things for those who need them. Hospitals don’t have to eat the cost of providing care to as many people, because everyone has insurance, and the insurance companies will pay for their care. And the insurance companies can do this, because the pool of money now isn’t just coming from the few people who are actually going to need payouts. It’s now like the homeowner’s insurance; a lot of people are paying into the system for care they won’t end up actually needing. And yet, the amount they’re paying is far less than the invisible amount they were paying before without knowing about it.

And, and this is HUGE, people can get treated BEFORE their illness gets so bad it becomes an emergency, or a chronic condition requiring repeated trips to the ED. That guy before with the diabetes? Instead of paying for his amputation and rehab and taking care of him for the rest of his life? You’ll only be paying for his primary care doctor to teach him how to change his diet, and prescribe him some medication to keep his blood sugar under control. Guess how much cheaper that is than doing it the other way?

Hospitals will stop being broke because they will get paid for services, and medical costs will even out over time. Not all at once, because this mess has taken a long time to make, and it’s going to take time to fix it. But it will happen.

They’ll also be able to actually hire adequate numbers of staff, so care and safety will improve. Nurses can take care of patients again, instead of having to also do secretarial and housekeeping duties. People will be able to work and continue being contributing members of society and be healthy instead of being chronically ill and miserable and going on disability. Insurance costs will level out as medical costs do. Employers will be able to raise salaries appropriately without cutting into their profit margins, and people will be able to afford to live because their income will better keep up with increased cost of living. The economy will improve.

And, 10 or 20 years from now when that heart attack hits? You’ll be able to go to an emergency department and get the care you need. And you probably won’t have to wait 4 hours or be treated by overworked doctors and nurses trying to juggle more patients than is really safe. And you’ll recover, and go home, and see your grandchildren grow up. And so will a lot of other people who would have died years earlier if we stuck with the status quo.

Change is hard. It’s uncomfortable. It’s upsetting. But things that don’t change stagnate and die. Change is how we grow, and get better.  Think of it as an investment. Pay now, profit over the long term as the system rights itself. And have the peace of mind of knowing your children and grandchildren will not die for lack of emergency medical services if their appendixes rupture, or they fall out of the neighbor’s tree and break their arms and legs, or get hit in the head with a baseball.

It’s win-win for America. Period.

Oh, yeah. If you still want the link to that other story (and the movie to go with it), you’ll find it here: The Accidental Op-Ed

I realized my faux pas just as her son began to translate what I had said, and knew from his expression he had realized it at almost the same instant. He shot me a wincing half-smile while he finished what he was saying to her, and we both watched as the tension in her face eased a little, and she turned her attention back to her husband.

“Ummm…sorry,” I told him. “I guess that didn’t do much to put *your* mind at ease…” He grinned and shrugged. His goal had been to try to calm some of his mom’s anxiety during this difficult time, and we’d accomplished that, at least…”You know,” I reassured him, “medical science is making great progress toward preventing dementia…”

*sigh*

That thing where you’re supposed to focus on the person you’re having the conversation with, and pretend the translator isn’t really even there? Turns out that thing can kinda backfire on you sometimes.

Psychiatric practitioners, as a rule, tend not to wear white coats as much as in other medical disciplines. I’m not sure why. Maybe it’s because of the old Napoleon XIV song, with its maniacal “They’re coming to take me away, ha ha!”

Our team was recently discussing some of the problems of practicing psychiatry in the midst of a sea of medical practitioners, however, and for a variety of reasons, we decided to start wearing white coats, among them that it helps to make our role clearer to patients, and doctors who walk in when we’re doing an interview are less likely to assume we’re a visitor or someone from admissions or something and hijack our interview right in the middle of a sensitive discussion. There were more reasons, but you get the idea.

Yesterday, I experienced an unexpected result of the move to white coats. In our hospital, as in many others, a “code gray” is called to alert staff and security of a behavioral incident–someone’s behavior has escalated to the point where it is disruptive to the other patients, or there is a concern for the safety of patients and/or staff. Our team responds to codes gray, if at all possible. There are only 2 or 3 of us in the hospital at any given time, and we’re only there during the day, and depending on what we’re involved in, we can’t always get there. But we do respond, the majority of the time, to daytime codes gray.

Yesterday there were a LOT of codes gray. And a funny thing was happening when I showed up.  Every single time, without exception, I was greeted with exclamations of surprise and gratitude; “Oh! You guys are responding to codes now?” “Wow, so it’s just like a rapid response or something now, you guys come too, huh?”

This was really puzzling to me. Why were they so surprised? We show up for codes a lot; sometimes more than one of us. But since I was preoccupied with finding out what was going on and trying to help resolve the situation, which in yesterday’s codes was consistently “angry demented but surprisingly fit elderly man wants to beat up everyone between him and the exit,” I didn’t really have time to stand there being puzzled, so each time I shook off my puzzlement and jumped into the fray instead.

Weird as it was, It might still have escaped my notice, if one of the codes hadn’t been on the unit that tends to get most of our more difficult psychiatric patients. And if ANYBODY should know we show up for codes gray, it should be them. Plus, the comment wasn’t just from some float nurse who wasn’t used to how things work there. It was the charge nurse. I’ve *personally* dealt directly with her numerous times when assisting with codes gray.

It was all rather disconcerting, but it was such a busy day that I really just didn’t have time to think about it. Until now. And it finally dawned on me what the difference was. I’ve been there two years, and have nearly always showed up when there was a code gray during my shift. My teammates have all been there much longer, and have also been responding to codes, for YEARS.

BUT…

We never showed up in white coats before.

I’ve known for a long time that white coats are powerful. I think I first learned it from my brother Jon, who graduated from medical school at an age where most people are just getting started, and who got laughed at by cops when he stopped to help at car accidents, until he started carrying a white coat and stethoscope in his trunk to wear at accident scenes, because then no one ever questioned him.

I had no idea how invisible we were, even all the times we single-handedly de-escalated difficult patients or had an instrumental part in helping to resolve a situation, until the very same people who we helped out all those times before were surprised yesterday when I showed up.

Wow. I might just start wearing my white coat everywhere I go.

I’ve graduated, passed boards, been duly board certified, applied for licensure in two states, and can now proudly claim to be an Advanced Registered Nurse Practitioner (ARNP) in the state of Washington. All I’m lacking now is a DEA number to prescribe controlled substances. Until then, all I can prescribe are “legacy drugs,” which basically means aspirin.

I’m still awaiting for my Oregon licensure to be finalized. It was a much more tedious process and took me a lot longer to finish, so I predict it will also take them longer to complete. That’s okay though, because I’ve got to get in some more overtime before I can afford a second DEA number. They don’t come cheap.

Meanwhile, I’m trying to figure out what to put on my business cards. In Washington, I am an ARNP, while in Oregon, I will be a PMHNP (Psychiatric and Mental Health Nurse Practitioner). Do I get different cards for each state? Or put both titles on one card, in which case there’s not room left for much else?

Ahh, conundrums.

Dear Ruth,
Please tell me you can move to wherever there are jobs. If you cannot I am so very sorry but I cannot help you. My focus is on meeting the needs of my communities and find them candidates who will practice there. It is not, sorry, on focusing on the candidateâ€s specific job needs. EXCEPT as to how they meet the needs of “my” communities.
And I have to say, unfortunately I do not have hardly any communities with which I work in SW Washington, not to say there is not need. And I donâ€t do Oregon.
Look forward to your response and I do hope we can work together. Sorry for seeming so blunt but I find being honest and to the point saves us all a lot of time.

Apparently, this person got my information from one of the job posting websites I’ve browsed through while seeing what potential nurse practitioner jobs there might be in my area. So as far as I’m concerned, this was a cold contact by a recruiter, connecting with a potential job candidate in a profession for which there is a HUGE demand. I wonder how many eager new recruits they have rushing to work with them?

Here’s my response, which I wrote instead of going to sleep after night shift like I was supposed to be doing:

Dear ***,

I’m confused. If I had actually approached you with a list of totally unrealistic expectations and asked you, at great inconvenience to yourself, to go out of your way to help me find a job, perhaps such an unprofessional response might have some merit.

But I didn’t. YOU contacted ME, and as far as I could tell at first, completely out of the blue. It wasn’t until after I’d been bowled over by your message that I reached the bottom where the information from *** was attached, and realized why you were even emailing me in the first place.

I have absolutely no prior knowledge of who you are, what you do or don’t do, or what constraints you operate under. Nor do I have any expectations of your doing anything for me that won’t benefit you (or your clients). So basic societal norms (read: cultural competence!) would indicate that you don’t start right off making assumptions and blasting me for daring to not have the exact qualifications you are looking for, or for being interested in jobs in a state that you don’t handle.

Perhaps a friendly introductory letter explaining your focus, describing your territory and the rural locations of the available jobs, and offering the fact that relocation is usually a requirement, would convey the same message at the same level of honesty, while not souring potential candidates on the idea of having anything to do with you whatsoever.

Being a busy grad student and nurse meant I thought I didn’t have time for DIY projects, so my original intent was to purchase a pre-made coop and chicken run. To my amazement, I found a chicken tractor on Amazon.com–with FREE super saver shipping! I happily placed my order.

A week later, Amazon informed me my order had been canceled due to unavailability. Frustration set in. I searched in vain for another source, but couldn’t find anything I liked as much that was within my price range. It seemed that building my own was my only option, but I didn’t see how I possibly could. For one thing, we don’t have much in the way of woodworking tools. Also, finals week was fast approaching, and “spare” time was at a premium. I needed to come up with something I could do quickly and easily, without too many fancy tools. Here’s what I came up with:

I bought a Rubbermaid storage shed at Home Depot.

Inside, I added a roost and a rack to hold the “nestbuckets” made from Home Depot buckets. I also made a screened wall on one side, so that one door can be left open for ventilation during nice weather.

To secure the wooden fixtures, I drilled holes through the walls of the coop and screwed wood screws through from the outside into the wood pieces. Where possible, I took advantage of the shapes and depressions of the plastic to add additional support. The screen wall is fastened to the wall of the coop and also to the roosts. The nestbuckets are not permanently fastened to the rack they sit on — I use a bungee cord to hold them securely in place.

In the back of the coop, beneath the nestbuckets, I cut an opening for the chickens to use for going in and out. I made a mistake and made it flush with the floor, before realizing that there should be a “lip” to hold the bedding in, so I added a scrap piece of lumber across the bottom for that purpose. I used strips of trim to “frame” the opening and hide the hollow walls of the Rubbermaid container.

Since there’s no way to keep the right-hand door closed when the left-hand one is open, I added gate latches on the inside to fasten it to the screen door. I can easily reach the lower one by reaching down through the top of the coop, but for people whose arms aren’t as long as mine, a pull string could be rigged for that purpose.

The last step was to add four eye bolts to the outside of the coop, to secure it to the run (I’m using bungee cords for this purpose), and to add strips of 2×2″ lumber to use as handles, since the smooth plastic makes it hard to get a grip on it for transporting the coop.

The run is made from two cattle panels with 2×4″ openings, using pig rings to secure the pieces together. The sides and top are each a half panel. The remaining piece was cut into 3 parts. Two of them form the end of the run farthest from the coop. The bottom half is fastened permanently in place, and the top half is fastened only at the top, forming a hinge that allows it to be swung up onto the top of the run for access to the inside. Again, I used a bungee cord to fasten the access panel in place when it is closed. I’m tall enough to easily step over the lower piece, but someone without my height advantage might need to modify the design to work for them. The remaining thin piece of cattle panel was fastened vertically to one side of the end of the run next to the coop. It adds some structural stability as well as allowing for the fact that the coop is not quite as wide as the run. A 2-foot wide strip of hardware cloth with 1/2″ openings was fastened all the way around the lower portion of the run, to keep raccoons from reaching through to grab the chickens.

Finally, I fastened a tarp over the run at one end to protect the feed from rain. Here’s the finished product, complete with chickens: