Dr. Dror Paley is midway through his 12-hour day fixing children's arms, legs and hips when he steals away to a staff lounge for a chocolate protein shake.

As he mixes some powdery stuff with ice cubes and turns on the blender, the Baltimore surgeon gets word that his wife and kids are stopping for a meal north of Toronto on the first day of their vacation. He remembers the gourmet chef the family discovered in the middle of nowhere on last year's annual trek to Canada.

"That's probably where they are headed," he muses.

A second is all he has to lament not being with them. People are waiting on him at Sinai Hospital: children from other states, children from other countries, and the parents of a 15-year-old who must drive through the night to Saginaw, Mich., to arrive in time for her first day of school. Hurry, hurry.

Ah, August, the busiest month of the year for a pediatric orthopedic surgeon with a rare specialty: limb lengthening and reconstruction. The season for Paley begins in late May. Surgery is only the start of the process that can add 3 inches to a child's height in a single summer. In the stretching phase, which lasts three months, the bone is held in place with pins. That's when most complications occur, and Paley can't be sloppy; to head them off, he checks on his patients every two weeks.

Beginning in May, then, 10 to 15 patients a week are added to his clinic after surgeries. The load builds until August, when the waiting room of the International Center for Limb Lengthening, which Paley runs with partner John Herzenberg, is out of control.

Outside, traffic in Baltimore has slowed and parking garages are half full as families head for the beach or the mountains; Paley, the most experienced surgeon in the country in his specialty, hasn't noticed. He arrives at 6:30 a.m., often after a 6-mile bicycle ride.

At this hour, a few minutes after 2 p.m., the delay from appointment to actual examination is two hours - not bad, compared with the previous week's five hours. Only one of 58 scheduled patients and five surprises has left in a huff; the others sit or stand patiently, entertaining their children in a large playroom, reading books, glancing at the television or walking up and down the hall.

Paley runs between the X-ray viewing room and patient examining rooms, with an odd trip up a back staircase to operate. The climb up two flights of stairs is the closest he's been to hiking since June, when the family sneaked away for a week to Banff and Jasper national parks in Canada. Paley, who is 46 and Canadian, loves camping, hiking, canoeing, rock climbing, fishing.

But now, instead of being followed by moose and elk in Ontario's Algonquin Park, he is being followed by a couple of residents and a Boston freelance writer researching a book on dwarfs. Five percent of Paley's operations are to lengthen limbs of those born with achondroplasia, a bone disorder that causes dwarfing. Most of his patients have other deformities, such as a short thigh bone or a missing fibula, the narrow bone next to the main shin bone.

Paley brought limb-lengthening to the United States in the 1980s after studying it with experts in Russia and Italy. Doctors still have little use for it, with most recommending amputation rather than growing the bone, a treatment once considered worse than the disease. Paley changed things, writing the textbook for a new generation. Little did he know how much his summers, too, would change.

In one examining room, he gives new instructions to the mother of an 8-year-old girl from New Jersey about the gadget attached to her arm.

'Give the kid a break'

With a Lucite ruler, he measures bone growth on the child's X-ray and calculates how much the mom needs to turn the pins. The turns pull the bone apart, stretching it, so new bone can grow and fill in. The mother is anxious to have the child's other arm lengthened, but Paley is not. Two things have to happen, he says: "The arm muscle has to recover. And, give the kid a break."

A teen-ager on growth hormone gets good news: Her legs are now less than an inch different in length, and Paley is not inclined to operate on the shorter one. "See you back next summer, and maybe you'll be equal," he says.

Before Paley can get to the next examining room, a mother in the waiting room, Crystal Kappenman, spots him and rushes down the hallway with her daughter, Rachel, hoping to salve her worry: The child, who uses a wheelchair, had her leg caught on a carousel over the weekend, she tells him, and now green goop is oozing from the hole where pins are pulling the bone apart. Is the leg infected?

"Let me see," Paley says, but he can't see, not until the bandage is removed. He'll take a look when she gets into an examining room, he says, reassuringly. The mother nods and returns to the waiting room.

Walking back quickly to the handwritten list of patients who have checked in, a small tension creeps into Paley's voice. "Who am I seeing next?" he asks. "How are we doing on getting follow-ups in rooms?"

Paley can't afford to get behind so soon, or the afternoon will be impossible.

He runs upstairs, scrubs, and enters the O.R., where he cuts into the subcutaneous tissue of a little boy's stretched leg with scissors, reducing muscle tension and improving the look of the leg. It takes 10 minutes. He does a few of these on clinic days.

Back inside a patient's room, Paley sounds like he has all the time in the world. His voice is calm, his demeanor direct and personal, no matter that he's been asked the same question hundreds of times after thousands of operations. He laces shoes, watches children walk and run, recalculates their bone growth and gives parents an idea of what to expect in 10 years.

One toddler will probably stand about 5 feet 9 inches in adulthood. Another boy, Kevin Mullarkey of Boston, can only hope to walk comfortably. He is a dwarf. The boy has grown 4 1/2 inches since his operation a year ago. Now he needs therapy to strengthen his hip muscle. "Within six months he'll be walking and running normally," Paley says. He poses with the boy as his father snaps pictures.

Patients might be scheduled for 10 minutes, but Paley could be stuck in the room for an hour. He will stay as long as they have questions, and they know that.

That's one reason he runs late.

Nobody complains - not to him, anyway.

On his way out he is stopped by an aide who asks if a patient with only one question could be seen now instead of hours from now.

"No patient is going to get in front of the line," Paley says firmly as he whizzes by. The scheduler nods; all she wanted was to be able to tell the patient she tried.

The patient Paley checks next has been squeezed onto tomorrow's surgery schedule at 7 a.m. The patient wanted a later slot, but the doctor said no. It is now or never. Paley sees that the man's name is not even on the surgery schedule. Be sure the patient knows to get here at 6 a.m., he orders.

Tough talk

The next patient, a teen-ager, is a worry; the strap tying her foot to her frame is not tight enough, and the foot isn't in the right position. "If you don't get serious, she will be stuck in this position," he tells the parents. He doubles her daily therapy to a "full" hour. He is being stern, he says, because this is serious.

He's wearing his purple surgery hat when he tells a family from India that the only way to fix their son's leg is to remove the rod he implanted earlier. It's broken. This is the first problem in a decade for the boy. Paley wants to treat aggressively, because when the boy's leg has grown the last 3 inches and he can walk like anybody else, no one will remember the problem.

Up in Canada, the rest of the Paley family is moving closer to what wife Wendy describes as a celebration of "moose, deer and total togetherness." After 21 years (they celebrated their wedding anniversary this week, too), Wendy is not about to pout. C'est la vie, she says as she drives into the wilderness hours north of Toronto. She is not going to sacrifice the family vacation.

The family has been taking the same trip for seven years. Patients alone didn't cause Paley to miss it. Three years ago, he agreed to play a major role in an international conference being held for the first time in the United States. It begins in San Diego this week. If he had been invited today, Paley says, he'd get out of it in an instant.

Missed vacation

He has already canceled another week of vacation. Paley was supposed to take his daughter skiing in late July after a medical meeting in Argentina. That was before a father from Saudi Arabia showed up to have his daughter examined, and Paley concluded she needed surgery. I am here, the father said. What about now? The man's company was paying for it, and he might lose the money if the procedure was delayed.

Paley's surgery schedule is "beyond fully packed" months in advance of summer. Normally he operates Monday through Thursday, and devotes Fridays to administrative matters at the 130-staff Rubin Institute for Advanced Orthopedics at Sinai.

He fit in the Saudi girl and others by canceling his meetings and operating on Fridays, too. But that only gave him two or three more operations a week. To do the 20 extra surgeries he agreed to this summer, many of them for foreign children, he needed an extra week. So he canceled the ski trip.

By late afternoon, Paley is eating Mexican candies, a gift from a family that moved north for the summer so Paley could treat the son. Like many foreigners - they also come from Jordan, India, Canada, Venezuela and Italy - this family didn't need a translator. Paley speaks six languages.

The room where Paley views X-rays and consults with residents is littered with coffee cups. By the time he gets to Andrew Annello of Birmingham, Ala., the wait from appointment time has grown to four hours. "You don't have a plane back tonight?" he asks Marie Annello, the boy's mom. No, she says, smiling, "I learned the hard way."

The wait annoyed her when Andrew was 18 months old - it's hard to keep a baby in a hospital all day - until she realized she had met a miracle doctor. Paley offered "true hope," she says. The other doctors wanted to amputate. "He's worth it," she says.

Andrew, now 11, has nearly full use of his once-flawed leg.

It is not without cost. Right now in the "adjustment room," also known as the garage, Paley uses a 2-foot orange pliers to try to loosen a bolt so he can change weights on the frame stretching Andrew's bone. The doctor looks as if he is clowning around with the oversized pliers until the child cries out in pain. "Sorry, Andrew," Paley says, "hang in there, Andrew, you've been real good."

Day's end

It's 8:15 p.m. when the last patient is seen. Paley returns to the X-ray room to dictate the last two cases. Then he crumples the list of the day's patients into a ball and throws it into the trash. Done, except for a late-night dinner with the Boston writer who wants to debate treatment for little people.

The day has been relatively pleasant compared with the previous week's clinic, when he saw 75 patients until 11 p.m. He has figured out a way to predict leg-length discrepancy at maturity and ways to fix it, and now his goal is to reduce treatment time.

Up in Canada, it's raining. The rest of the family has decided to put in their canoes another day.

Labor Day is around the corner. But Paley can't rest yet. The next Tuesday, when the kids are back in school, he begins his annual seven-day course for doctors who want to learn his specialty.

Maybe then he'll take a vacation.

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