By Desmond Bell • Frank Aviles • M. Mark Melin

If you have been a member of the wound care community for any length of time, chances are good that you have heard of “SALSAL” or The Save a Leg, Save a Life Foundation. You may have previously seen our White Sock Campaign, aimed at raising awareness of leg amputation prevention by wearing a single white sock on the outside of your clothing. Raising awareness of the epidemic of leg amputations associated with rising rates of diabetes, metabolic syndrome, hypertension, and hyperlipidemia is crucial for the American Vein and Lymphatic Society (AVLS) community given the number of wounds evaluated within vein clinics. It is prudent that we accurately diagnose wounds as not simply venous leg ulcers simply because the patient presents to a vein center. Many “atypical” wounds (pyoderma gangrenosum, skin malignancies, Martorell hypertensive ulcers, etc.) will also be in the differential diagnosis, as will the growing rates of diabetes-related lower extremity ulcers. Physicians and providers in vein centers can contribute to the recognition and diagnosis of peripheral arterial disease (PAD), which is important not only for improving outcomes but also prevention of inappropriate venous ablation and sclerotherapy in limbs with PAD.

Mission Overview

SALSAL is a 501c3 non-profit organization, incorporated in 2015 whose mission is to reduce the number of lower extremity amputations and to improve the quality of life of our fellow citizens who are afflicted with wounds and complications from diabetes and PAD. Dr. Desmond (Des) Bell is the founder of SALSAL. His primary goal was the creation of a non-profit organization with the intent of addressing discrepancies and disparities in the quality of wound care being delivered to patients receiving increasingly complex management of chronic wounds.

In a supportive and visionary effort to include home care and community efforts in wound healing in Jacksonville, Florida, the idea and foundational concept were formulated to help address common issues that ranged from bandaging techniques, compression wrap application, and basic vascular assessment (ankle brachial indices, venous competency studies). The initiative began by inviting nursing directors from ten home health agencies to attend a lunch and learn about wound care basics and new technologies.

One successful “lunch and learn” evolved into a local forum that was open to all, and eventually evolved into The Save a Leg, Save a Life Foundation. The process began in 2004 and through accomplishments and many learning opportunities, the current version of SALSAL is poised to finally take the mission and vision to the general population, broadly engaging communities, patients, providers, and home health care agencies who most need our help in navigating the issues surrounding living with chronic wounds, amputation, and the toll these eroding factors have upon the patient, their families and the “system.”

“I have seen incredible advances in technology as well as a greater understanding regarding how wounds are managed. Where we are today makes the days when I began treating wounds seem archaic," says Dr. Bell. “Alginates were cutting edge; there were no negative pressure systems, no cellular tissue products, and endovascular procedures were not being done to restore perfusion to lower extremities. Research and education have also made tremendous contributions, and the emergence of wound care as a medical specialty is no longer debatable,” he adds.

Despite all the improvements over the last 25 years, the most challenging aspects are the increasing number of diabetics in the United States (an estimated 34 million people in 2022), and the rise in amputation rates since 2015. We attend yearly conferences, become certified in wound care, and dedicate our lives to the well-being of our patients, yet why are morbidity and mortality rates of patients with diabetic foot ulcers, peripheral arterial disease, and amputation occurrence bleak when compared to various forms of cancer diagnosis and treatment? Why have breast, testicular, lymphoma, and other malignancies seen declines in mortality and improvements in quality of life for those suffering from these conditions?

Yet the issues associated with diabetic foot ulcers seem to only worsen. Why is a life with diabetes and the risk of amputation foregone conclusions among specific ethnic groups? Why does a perception continue to exist among many providers that diabetics created their own health issues because of lifestyle choices?

We know that prevention is preferred over treatment of any disease, yet why is there a relative lack of attention given to chronic wounds like diabetic foot ulcers, as compared to the attention that breast cancer has received over the same 25 years? This in no way lessens the efforts in caring for those with cancer but is meant as a disparity in attention to disease processes with overall similar morbidities and healthcare challenges.

A recurrent diabetic foot ulcer, once healed, is akin to a cancer recurrence (an oft presented analogy and educational point credited to Dr. David Armstrong, Keck School of Medicine, USC, Los Angeles). Long­term surveillance programs are needed to maintain diabetic feet in a perpetual healed state, though this requires a holistic care approach to improve insulin and drug coverage, diabetes monitoring, toenail cares, shoe wear, macro-and micronutrient awareness (and insurance/CMS coverage), and improved education regarding “mixed ulcers” (venous pathology and peripheral arterial disease). Patients having mixed etiology wounds or atypical wounds will greatly benefit from enhanced, collegial, collaborative relationships between veins centers and wound centers.

Many questions are posed here, yet the honest answers seem to have eluded most of us, and the messaging to the general population has not successfully resulted in a dramatic growth in public awareness. The pink ribbon campaign, a brilliant manner in which to highlight breast cancer awareness, captured the imagination of both the healthcare community and the general population. As a result of self-examinations and “buddy checks,” vast improvements have been made in research, treatment, and most importantly prevention of breast cancer.
Education is empowering and teaching individuals the “how and why” results in patients and family members arising to become their own healthcare advocates--a wonderful equation for success. Information is important but inspiring a change in behavior is the critical and essential element.

We have numerous medical and academic yearly society meetings in wound care, podiatric and vascular specialties, whose collective focus is noble. However, what are the tangible takeaways that translate into near-term system changes as a result of the data shown? Integration of new data, benchtop to bedside, often can take three to seven years. And the local communities where societal meetings are held, often derive none of the medical knowledge shared at those meetings. The disconnect between the healthcare community and the public must become a key part of the focus if our efforts are to have an instinctively widespread impact. The public cannot be expected to grasp the concept of what is at stake regarding chronic wounds and amputation and become proactive in their own care if this information has not been adequately delivered. When “we” deliver a diagnosis of diabetes to a community member, how do we instill a sense of responsibility in our patients and families and the medical community that prevention of complications is a high calling?

SALSAL Messaging and Outreach

For SALSAL leaders, partnering with community event supporters and wound technology industry leaders, creates inroads. The issues we are all working against are multi-faceted, and the solutions require more than one approach if collectively we are to succeed in reversing these worrisome trends.

The SALSAL Foundation has developed several methods to drive messaging to the medical community and general population through several undertakings. While each method appears to be independent at first inspection, all are related and specifically designed to further increase and broaden awareness as a call to action.

Community outreach in the form of health screenings combined with education began as a pilot program and has gained traction since our first large-scale event was held in November 2020. Working intentionally several months upstream with local wound care clinics, providers, community nursing, medical and podiatric post-graduate programs, efforts are coordinated pre-event to assist in screening a focused population at increased risk for diabetes, PAD, and amputation. This method has proven to be successful not only in identifying previously undiagnosed and now suspected pathology, but in connecting patients to the appropriate local community providers.

Identified conditions that have resulted in local referrals during SALSAL community screening events include symptomatic and asymptomatic PAD, congestive heart failure, and neuropathy. For example, an individual was identified to have detached retinas and assisted with urgent same-day evaluation. Additional community screening events are being planned for 2023 and 2024. The most recent successful event was held in San Antonio in early November of 2022.

The White Sock Campaign was created to draw attention to the condition of the lower extremities and create teachable moments between the individual wearing the single white sock and the person inquiring as to why the white sock is being worn in such an unusual and unique way. What began as a way to create awareness of PAD during each September (PAD awareness month) has spread to a year-round phenomenon with participants posting social media photos from countries all over the world wearing a single white calf-high sock.

The Harold L. Johnson Memorial Scholarship was created to assist and encourage wound care providers to sit for the board certification examinations administered through the American Board of Wound Management. The Scholarship gives preference to veterans, as Harold Johnson was a Vietnam veteran. His greatest personal fight was against diabetes and renal disease, and he lived his left to the fullest as a double amputee. Harold J. Johnson remains a beacon of light to educational efforts to improve wound care education.

A patient assistance program was also established to provide those in financial need the “essentials” for healing or to prevent wound recurrence, often not a covered insurance benefit for these most vulnerable patients.

Wound supplies, diabetic shoes, socks, walkers, roll-about walkers, and canes are some of the items that have been distributed to individuals and other entities through SALSAL and its association with generous donors.

Hurricane Dorian relief to the Bahamas was another way to raise awareness while supplying community outreach. Nassau, Bahamas, residents were devastated by Hurricane Dorian in late 2019. SALSAL provided 100 pairs of diabetic shoes (through the generosity of Anodyne Shoes) and socks while assisting students from Barry University with Podiatric screening and services.

The Vision Remains Crystal Clear

In summary, The Save a Leg, Save a Life Foundation has been built on 3 key principles.

• Education of both the medical community and the general population
• Advocacy and integrated community outreach.
• Marketing the critical concept and importance of amputation prevention as a multidisciplinary advanced practice concept that demands both medical and local community engagement.

If the general population truly understood the devastating nature of chronic wounds and amputations from the patient, wound care provider, and family perspective, there would likely be a much greater sense of urgency to solve the problems outlined here, as well as an outcry and demand for better holistic care.

Walking a day in someone else’s shoes is always better if you must put on two shoes. Empathy demands a realistic perspective of these losses to limb, job, economic vitality, family functionality, and the cost to the community. The Save a Leg, Save a Life Foundation has resonated with all that have donated their time, talents, and efforts, but our target audiences are incompletely reached. Our mission is driven by the love of our patients and the desire to end often unnecessary suffering.

To learn more about SALSAL visit https://thesalsal.org/