Right hand on the exam room door at the emergency hospital, a staff member leans in toward the white-faced, red-streaked people inside. Left hand held out where the client can't see, behind the door towards us. We are gathered close around a small figure on a steel table dripping blood and holding very still, breathing far too quickly. We are equally still, almost holding our breaths.

"The doctor says your dog is critical, and she needs your ok to spend $500 just to stabilize him."

Thumbs up, yes, we have the ok to treat! We move quickly, carefully toward the dog with pain meds and oxygen, fluids and bandages.

Thumbs down and we sag a little, someone steps toward the table to comfort the dog while I move toward the room to explain the need for euthanasia if we aren't going to treat.

Most people handle the situation with amazing grace, making their decision quickly and well. In an emergency they know it's serious, and they know they're going to have to deal with serious decisions about life, pain, death, and money. Big money.

Money can get very big very quick in an emergency, or when an animal is sick. Mostly people are ready for that when there's blood and fear and pain and disruption, but not so much when it's some deceivingly simple thing like a lump or a bad tooth. I explain how what we are seeing could be a sign of something more, maybe much more, and what tests I need to do to tell them if it is, and what we might be able to do about it. And that's when I hear the question.

"Uh, Doc..." A pause, eyes darting around the room, at hands, feet, sidelong at each other. Eventually, usually, sooner or later, at me.

"Uh....how much is this gonna cost?"

I don't mind hearing that question. In fact, I love it. I don't know if it's because of their experience in human health care or a lack of experience with veterinary care, but many people honestly aren't prepared to have us put a price on what we need to do for their pet.

But that is exactly my job. It is my job to tell my client what care their pet needs and why. It's your job as a client to decide what you want to spend. You are not being cold hearted when you ask how much or when you tell us you don't have it or don't want to spend it. And we're not being heartless when we tell you how much or when we don't back down because you don't agree it's worth it. It costs a lot to keep an ER staffed overnight with appropriate equipment.

It's ok not to have money. It's ok to have it and not spend it, just like it's ok to have it and spend it. I am slightly shakier on whether it's ok to spend it if you don't have it, by using a credit card or using up savings. I worry that living beyond our means as individuals got us into our current national economic mess. But in a room with you in the middle of the night, my job is not to fix the economy. It's to tell you what it's going to cost to try to fix your broken animal and your breaking heart.

Your job then is to tell me how much you are going to spend. You are the best person to make that choice. I don't get to choose for you by low-balling the estimate or by padding it, or by not giving you one and just doing what I think needs to be done. I know that's how it goes in human hospitals, where we have divorced spending and paying with sometimes awful consequence. But not in the veterinary hospital; here what we do is entirely the client’s choice.

Clients make all the choices when it comes to treatment. Some may have made some choices that likely steered their pet into this ER, even if they didn't realize they were making choices that turned out to have long-term impact. I’ve seen some terrible results from certain choices.

Met a total stranger in a store parking lot and paid $400 for a puppy that was advertised online
This is probably not a good choice, although I’ve seen some great dogs acquired this way. Also some real disasters: open fontanelles, heart murmurs, poor conformation, parasites, or infectious disease. A lot of times it’s nothing that bad - just a scrawny, slightly grungy pup that needs TLC, good nutrition, deworming and vaccines.

Skipped the vaccines and now the dog has parvo
This choice frequently turns out worse than the previous one. The vaccines work; a properly timed series of properly handled vaccine given to a puppy that was healthy and well nourished enough to mount a solid immune response confers almost lifetime immunity. But a lot of people find themselves short on cash after laying out the price of the pup. So they don’t get any shots, or they try to do them at home with vaccine from the feed store or a catalog. Or the breeder says ‘He’s had all his shots,’ and the owners don’t realize that means he’s had all his shots SO FAR; he never got the boosters. Unfortunately, parvo is everywhere. Treatment is usually successful but always expensive. A lot of people just can’t bring themselves to come up with the money.

Didn’t neuter and then let him roam
An owner chose not to spend the money to have the pet neutered, and then made a second choice to let him roam the neighborhood. Now he is in the ER with an arrow through his leg, and it might be lodged in his femoral artery so I definitely need the owner to sign a four-figure estimate giving us permission to go straight to surgery and give transfusions if blood hits the wall like water from a hose when I pull that arrow out.

This particular case, which led to white-faced, red-streaked people, was actually the sum of several bad choices. The owners weren’t bad people. I can literally count on one hand the number of bad owners I have encountered in the years I’ve been doing this; I remember each one of them. On the other hand, I couldn’t begin to count the number of people who have made bad choices.

In this case realizing the consequences of the choices they’d made hit the owners as hard as the arrow hit their dog; their attitude hit me equally hard. Initially they wanted to blame somebody else for the consequences of the choices they’d made. It was not a pleasant conversation. I pointed out that it wasn’t their intact, unconfined male dog’s fault that he was roaming. The large sum of money needed for treatment wasn’t the hospital’s fault. And it’s not really the fault of whoever shot him, even if the owner can make it stick because he’s the chief of police, because the shooter didn’t let the dog out to roam.

The owners knew their choices led directly to their dog being shot with an arrow. It was, however, now our problem, theirs and mine and the dog's, there in the middle of the night. I know I’ve made some bad choices that landed me (and a few times my dog or someone else I loved) somewhere we didn’t want to be in the middle of the night. I’m glad I have the opportunity to help people when their pet has such a problem. But sometimes my ability to help first takes clients realizing that they made the choice or series of choices that caused the problem, that it’s going to take money to solve that problem, and that can be a real powder keg of a conversation for us vets to have to have with owners.

Fortunately in this case, it turned out to be much less of a problem than it could have been. The arrow was not in the artery and 15 minutes later the dog and owners walked out with recommendations for neutering and a leash. No blood on the ceiling, no transfusions, no emergency surgery, no white-knuckled wait, no huge sums of money.

Totally anticlimactic. As an adrenalin junkie, I was bummed because I was ready for a crisis that didn’t happen. As a dog lover and a dog owner, I was thrilled. Welcome to the schizophrenic mind of the ER vet.

People don’t intend to make choices that end badly and expensively, but once they are in an ER it's absolutely their choice what to spend. Any choice clients make is ok. It’s their money and their pet and their choice. I may not like it, but I don’t have to. I do have to do my job, which is offer care and charge appropriately for it so we can stay in business. The clients’ job at this juncture is to decide how much to spend. Hopefully, if I do my job well, those clients will leave with the information and sense of empowerment that they need to make better future choices for their pet and pocketbook.