Chapter One

“Heart rate’s climbed to 148,” Lauren Barclay warned, her words blending with a monitor alarm in dark harmony. The clatter of resuscitation equipment being hustled into place by fellow ER nurses snuffed out the rest of her report. A strangled gasp from the head of the gurney validated Lauren’s concerns: this man was failing in the painful struggle to fill his lungs. Her stomach knotted. They couldn’t lose him. Not the brother of one of their team.

Please . . .

“O2 saturation is tanking, Doctor.” She grabbed the hissing suction catheter and wedged closer, determined to get the physician’s attention. Her eyes watered at a sudden whiff of iodine and alcohol. “His skin’s really gray.”

“I see that, Lauren— I’m not blind.” The physician pulled the fiber-optic scope from his patient’s mouth, growling with frustration. “Suction! Clear his airway.”

“Got it.” Lauren moved in quickly, a respiratory therapist behind her with the Ambu bag. She slid the catheter between the unconscious man’s lips, struck again by the familiarity of his features: dark hair and lashes, that hint of olive in his complexion despite his pallor. She’d have known he was Eli Landry’s older brother even without seeing the medical record. Andrew Landry, thirty-six years old, had suffered a traumatic brain injury twenty-some years ago— a boating accident and near drowning that left him comatose on a ventilator for many months afterward. And severely disabled since. He was a man who should have been remarkably handsome, vital—embracing a hopeful, successful life—but was instead gaunt, withered, almost helpless. And dying?

Lauren glanced at his half-closed lids, the stray curl clinging to his clammy forehead. She’d never actually seen Andrew before today, but his tragic history was well known in Houston because his father—

“Hyperventilate him,” the doctor ordered as a respiratory therapist slid a mask over the man’s face. “And restrain those arms if you need to. Arm—
he only has the use of the left one.” He pulled off dark-framed glasses and wiped them with the hem of his scrub top, watching as the therapist began to squeeze the bag to assist respirations. “He’s going to quit breathing. If I can’t get this tube in, I’ll have no choice but to trach him.”

The physician ran a gloved finger over a thickened, pearly scar on his patient’s throat, uttering something that sounded like “Why me?” He met Lauren’s gaze at last. “Look, I’m sorry for snapping at you.” Despite the air-conditioning, the young man’s thinning hairline and forehead glistened with perspiration. Nervous sweat. It spread across the neckline and chest of his green scrub top, as if the stifling June humidity had slammed through the doors of Houston Grace Hospital along with the rushing ambulance gurney. “It’s just that—”

“He’s Eli’s brother,” Lauren finished in a raw whisper, the physician assistant’s name never failing to cause her discomfort.

“And Judge Julien Landry’s oldest son.” The doctor lowered his voice. “Eli and his father have been at odds about Andrew for months. Everyone knows that. I need to be in the middle of that battle like I need a hurricane to flatten my house.”

“I hear you.” Lauren’s gaze darted toward the hallway that led to the ambulance bay. The Caribbean was brewing a trio of tropical storms. She’d almost prefer that over what might happen here today. Things were tough enough without added conflict. She’d moved back to Houston—accepted a position in this ER—to keep a protective eye on her younger sister, Jessica. The twenty-one-year-old was making reckless choices, and if she didn’t straighten up, her job at Houston Grace was at risk. As was her acceptance into nursing school in the fall . . . and even her life? No. Lauren refused to believe Jess’s problems were that serious. Unfortunately, there was one thing she couldn’t deny: Eli Landry was part of the whole mess.

“Okay, then.” The doctor signaled to the respiratory therapist that he was going to attempt another intubation. He glanced at the clock, then turned to Lauren. “What time is Eli due in the urgent care?”

“Not till four, unless he’s heard—”

There were voices outside the code room doors. A woman, their emergency department manager. The other voice was much deeper.

“Is that . . . ?” The physician’s gaze moved to the doorway, and the room went strangely quiet except for the whoosh-burp of the plastic mask bucking against its seal over Andrew Landry’s face.

“Oh no.” The words slipped out before Lauren could stop them. “He’s here.”

- + -

Eli Landry shoved the code room doors open, telling himself the same thing he always did: he was prepared for whatever he’d find. After years of trying, he still hadn’t convinced himself.

“Eli . . .”

The ER doctor, Mike Duhain, walked toward him. Sweating—always a bad sign.

“Mike.” Eli looked at the heart monitor: tachycardic but regular. Only then did he allow his gaze to move to his brother’s face, partially obscured by a translucent green resuscitation mask. Alive. He released the breath he’d been holding. “What’s going on with Drew?”

“The care home told the medics he was breathing hard last night, sleepy today. Had a shaking episode. He arrived here with severe respiratory compromise and hypoxemia.” Mike glanced toward the monitors as an alarm sounded. “Oxygen saturation’s 89 percent even with the high-flow bag assist.”

“Fever?” Eli noticed for the first time that Lauren Barclay was in the room. Pink scrubs, honey-colored hair rebelling against the summer humidity. Only concern for his brother could have provided enough distraction to make him miss such a staggering sight.

“His temp was 104.2,” she reported, moving to the computer a few feet from where they stood. She managed to avoid Eli’s eyes—a skill she’d perfected since her return to Houston. Right now, he was grateful. The last thing Eli wanted—besides for his brother’s heartbeat to suddenly flatline—was to see disapproval in Lauren’s eyes. Had she heard what was going on with his family?

“We sent blood to the lab and they’re drawing for arterial gases now,” Mike continued. “X-ray is coming for a portable chest; I hear coarse crackles throughout. I’ve made a couple of attempts to tube him. I was about to try again with a smaller—”

“You won’t get a tube in,” Eli interrupted. “His trachea’s a mess. There’s scarring and stenosis. Every med student and rookie paramedic in the county has used my brother for practice.”

He knew he’d spit out the last word and reminded himself that Mike Duhain was a skilled doctor and a more-than-decent guy. He was also providing physician support for Eli’s shift in the adjacent urgent care department. It would be an unwelcome role reversal for a PA to direct a board-certified emergency department physician. And unethical because this was a family member, but . . .

“Drew had that first trach after the accident,” Eli explained further, “and then an emergency crike during a drug reaction three years ago—multiple traumatic attempts to get that tube in. More scarring. And he’s had fractured ribs, sternum, and a contused spleen when some cowboy first responder couldn’t tell he didn’t
need cardiac compressions.” Eli’s gut roiled. “My brother has been through way too much.”

Mike swiped at his forehead. “I hear you. But he’s in serious trouble right now.” His eyes met Eli’s, the meaning crystal clear: What do you expect from me?

Eli glanced at Drew with a sigh. “This is almost always pneumonia. Complicated by his asthma. He’s had some close calls the past two years. Ended up on a ventilator with ARDS last Christmas. There were heart-rhythm problems related to that.” Saying it out loud ripped a scab off things he wanted to forget: machines, tubes, shrilling alarms, sleepless nights. And his mother’s tearful midnight request for the Landrys’ pastor.

“I’ve put in a call to his pulmonologist,” Mike assured. “But right now . . .”

“If it’s early enough,” Eli suggested, risking a wish that it really was, “you might turn this around with BiPAP. It worked last time. Took a while, but it worked. Drew’s record will show the effective antibiotics.” He glanced toward his brother again as monitor alarms briefly sounded.

“Good. We’ll try that.” Mike gave an order to a second respiratory therapist, then turned back to Eli and lowered his voice. “The care home sent a copy of Andrew’s advance medical directive. It looks recent. And it says he’s a full code. No restrictions.”

Eli’s pulse quickened; it was time to do this. Past time. “That’s wrong. We’re revising it. It should say ‘no artificial life support.’” No more painful interventions.

“You mean . . . do not resuscitate?”

“No ventilator, no cardiac compressions. No defibrillation,” Eli confirmed, remembering his long conversation with his mother last week. He’d left the paperwork with her. “Comfort care. That’s what we want. If it comes to that.”

The silence in the room was broken only by the squeeze-whoosh of the Ambu bag helping Drew to breathe. Lauren’s fingers hovered over the computer keyboard.

“This is something new?” Mike asked, observably wary.

New? Eli had a sick urge to laugh . . . or scream. Slam his fist into the wall and shout loud enough for God himself to hear. Did that huge dented scar on his brother’s head look new? Did it seem anywhere near possible that he’d tossed a football around even once in the last twenty years? Could they begin to imagine how many times he’d been poked, prodded, choked, and tied down? Eli’s heart cramped at the truth: he could hardly remember a moment in his life when their family tragedy wasn’t reflected in his mother’s sad eyes.

“Yes,” he confirmed, aware of Lauren’s gaze. “It’s a new medical directive. I’ll make sure the paperwork gets—”

“Hold on.” Mike’s wariness morphed into an expression of visceral discomfort. He took a few steps away, indicating that Eli should follow, and dropped his voice to a whisper. “I had a phone call from the chief of staff.”

Ah . . . no surprise. Eli heard the gargle from aggressive suctioning of his brother’s scarred airway. “Let me guess—after he was contacted by Judge Landry?”

“It was made clear that your father is still responsible for all decisions in Andrew’s care. He alone. Not your mother. Or anyone else.” The physician’s grimace could sell antacids. “Your father apparently mentioned a restraining order. Against you.”

“Threat. Not fact.” Eli’s jaw tensed. They might as well string the Landrys’ dirty laundry through the halls of Houston Grace. Post photos to Facebook. “Look, Mike, no one wants Drew to pull out of this more than I do. No one. Anybody who says otherwise is way off base. But I can’t stand by and watch my brother suffer, only to end up on the kind of ‘life support’ that means no life at all. If Drew can’t beat it this time, or the next time or the next, I want to promise him some peace. I need to do that much.”

“I get that. I do. And I respect you, Eli. You know that. I feel for your situation. But my hands are tied.” Mike shook his head. “I think it’s best that you step away now. I’ll do everything I can to get your brother stabilized and up to the ICU.”

Eli glanced toward Drew; his brother’s face was now covered by a BiPAP mask. “Give me a minute?”

“Of course.”

Eli walked to the head of the gurney and rested his hand on Drew’s shoulder, gave it a squeeze. “I’m here, Champ.” A deep ache replaced his anger. He closed his eyes for a moment, remembering his brother’s laugh. Hoping against the odds that he’d hear it again.

As he turned away, Lauren Barclay’s eyes met his for an unexpected instant. Her expression was a cloudy mix of concern and . . . judgment? He didn’t need that now.

Eli sought Mike’s gaze. “If you try to tube him again, call me. Let me at least talk him through it. It helps if he hears my voice.” His heart gave a dull thud. “We’re a team that way. The first time we did it, I was eleven years old.”

Eli walked from the room, aware of the whispers and covert glances. He didn’t care. This was about his brother. He couldn’t let Drew suffer. Wouldn’t. And if it came down to a battle with their father . . . Well, that storm had been brewing for a long time.