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Carla Smith, MD is an orthopaedic trauma surgeon at St. Luke’s Health System in Boise, Idaho. She is also a board member of both SIGN Fracture Care and Orthopaedics Overseas, and has traveled extensively helping to bring orthopaedic care and education to low resource environments around the world. In this inaugural edition of OTA Member Spotlight, we talk with Dr. Smith about her experiences and her approach to medicine.

How did you get started in orthopaedic trauma?

I did my residency in Seattle at the University of Washington, and had quite an extensive exposure to trauma there. Almost until the end of my residency, I was undecided what my focus should be, but trauma resonated the most. I’ve had a couple jobs where I did some general orthopaedic surgery, but I almost always did trauma as well, and over time I focused more and more on the trauma components. Trauma fits in well with my interest in overseas work. It's worldwide, and the need for resources was really clear. Both of my interests went hand in hand and made sense together.

Did the overseas work lead to an interest in trauma or vice versa?

They are intermingled. I had done some graduate school work abroad, and even before I began residency training, I knew I wanted to go back. My involvement with SIGN Fracture Care underscored that as well. We started with fractures, and then by virtue of learning from our overseas partners and surgeons around the world, some of the same tools got used for deformity correction and other reconstructive options.

Can you tell me a little bit about SIGN?

SIGN was founded by Lewis Zirkle, MD, who still leads it, who I had the pleasure and great fortune to meet during my residency. He had been a Health Volunteers Oversees (HVO) volunteer in Vietnam after serving there. During his service, he recognized the need of the civilians and injured. Dr. Zirkle and an extremely talented engineer from Acumed, Randy Huebner, designed the SIGN Nail specifically to be used without radiographs in lower resource environments. The first programs were getting started when I met Lou and Randy during my residency. I've been fortunate to work alongside them and serve on the board of SIGN for almost 20 years now.

Since then, things have evolved. We have a database in which we ask surgeons to study the proficiency and safety of the SIGN Nail. We get to know them and we try to engage them with other educational opportunities and networking. In addition to the hardware nail, SIGN has grown into a collective of surgeons all around the world.

What kind of experiences have you had with SIGN?

I’ve been incredibly fortunate and lucky to meet amazing people. When I took my first trip, I was determined to go to Nepal. An individual I met there had finished his undergrad training and gone to medical school in Russia, and he was looking for residency. Through a SIGN connection, he ultimately did his residency on Mindanao in the Philippines. I got to visit him when he was chief resident and he had created a robust SIGN site there. They helped pioneer a mini open approach to femoral nailing, which is hard to do without C-arm. He's also on the board of a nonprofit that is trying to help increase the orthopedic care in the really rural areas, especially in far western Nepal. And he's become a mentor to another young, incredible Nepali orthopaedic surgeon who also trained in the Philippines, so we’re moving to the third generation.

The initiative it takes to learn new languages and travel to other countries to obtain an education, then come back and serve in your rural hometown is just awe inspiring. When I weave all of those threads together and think about the fact we've known each other for 25 years, and we've been able to meet up and stay in touch, it’s just an incredible story.

The brainstorming and ideas are always so creative and innovative. I’ve learned many things that I brought back home to my own practice. You end up gaining a tremendous amount of perspective.

How do HVO and SIGN dovetail? Or do they?

I would say the missions are almost the opposite of each other. SIGN really started with implants and targeted towards fracture, whereas HVO is entirely devoted to education and capacity building. They do start to intersect with people who inhabit both spaces. And orthopaedics is just one of a whole number of medical and surgical specialties that are represented in HVO. For example, one of the huge successes in virtual education during the pandemic was within our dental programs in Nepal.

Many HVO sites are also SIGN sites, but the organizational approach tends to be different. Both of them are geared toward enabling and increasing capacity of the in-country providers. But HVO has much more of a global health education bent, while SIGN is geared very much toward orthopaedics.

Can you summarize your own treatment approach and philosophy toward orthopaedics and medicine?

Some of the best advice I’ve ever received—and I'm going to give credit to Ted Hansen, although I imagine he wasn't the first to say it—is that if you listen to the patient, they'll tell you what's wrong. My hope all along is that I treat the patient in their own context within the direction of their goals and what they want. I see my role as very much education and helping to set expectations. The surgery is part of it, but the psychological components are extremely important, especially in trauma. Every patient and every case is different, and the same injury can manifest very differently across different people. It’s both frustrating and makes it more interesting.

What do you like to do in your spare time?

I love to be outdoors. I have the absolute pleasure of living in Teton County, Idaho, in view of the Teton Mountains and all of the other surrounding nature, so I love being outside. I enjoy skiing and biking and hiking and all sorts of outdoor activities.

I also stay pretty involved with a variety of organizations, including healthcare organizations and nonprofits in my community. It's really rewarding, and I think as clinicians we need to be visible and active and set standards and be leaders in our communities.

I really firmly believe that the earlier people are exposed to initiatives such as SIGN and HVO, the more they stay involved throughout their entire careers. My take home message is that if you're interested, just go try things—even during residency and in early career; the more things you try, the better. You don't have to stick with all of them, but some of them will stay with you. My early exposure got me hooked, and then I just made it a part of my entire career. The more opportunities we make for folks, and the more flexible we make careers so that we can continue to participate, the better off we all are.