The SALSAL Foundation and the Importance of Actions versus Words in Diabetes Care

If you have been a member of the wound care community for any length of time, the chances are good that you have heard of “SALSAL” or the Save a Leg, Save a Life Foundation. You may have even participated in our White Sock Campaign by wearing a single white sock on the outside of your clothing and posted a photo on social media. 

With that, you may not have a real understanding of what the Save a Leg, Save a Life Foundation is, why and how it began, and the vision as well as accomplishments of the organization to date. You may also have an interest in how to be part of SALSAL, and how you can join us in our mission.

To mark National Diabetes Awareness Month, a good place to begin would be an overview of what the organization is. We are a 501c3 non-profit organization whose mission is “To reduce the number of lower extremity amputations improve the quality of life of our fellow citizens who are afflicted with wounds and complications from diabetes and peripheral arterial disease.”

A Humble Beginning

The goal of creating a non-profit organization was hardly the motivation when the need to address discrepancies in the quality of wound care being delivered to my patients receiving home health became increasingly clear.

It’s too easy to blame others when things aren’t going well. Instead of a broad-stroke indictment of the home health nurses serving our region of Jacksonville, FL, an idea was formulated to help address common issues that ranged from bandaging techniques to compression wrap application and basic vascular assessment, for starters. The idea was to invite the directors of nursing of 10 home health agencies to attend a lunch and learn on wound care basics and new technologies. One successful lunch and learn evolved into a local forum that was open to all, and eventually into the Save a Leg, Save a Life Foundation. 

The process began in 2004 and through accomplishments and many more mistakes, the current version of SALSAL, which was incorporated in 2015, is poised to finally take the mission and vision to the general population.

These are the people who most need our help in navigating the issues surrounding living with chronic wounds, amputation, and the toll they take on themselves and their support systems/loved ones.

Actions as Well as Words

Having been a part of the wound care community for a good part of my life now, I have seen incredible advances in technology as well as greater understanding regarding how wounds are managed. Where we are today makes the days when I began treating wounds seem archaic. 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.

Despite all the improvements over the last 25 years, the most frustrating aspects are the increasing number of patients with diabetes we now have (16 million in 1996 to 34.2 million in 2022), and the rise in amputation rates since 2015.^1,2

We attend 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 diabetic foot ulcers (DFUs), peripheral arterial disease (PAD), and amputation bleak when compared to various forms of cancer? Why have breast, testicular, lymphoma and other cancers seen declines in mortality along with improved quality of life for those suffering with these conditions, yet the issues associated with diabetic foot ulcers worsen?

Why is a life with diabetes and even amputation a foregone conclusion among specific ethnic groups? Why does a perception exist among many that patients with diabetes created their own health issues because of lifestyle choices? We know that prevention is preferred over treatment of any disease, yet why is so little attention given to chronic wounds like DFUs, compared to the attention that breast cancer has received over the same 25 years?

Lots of questions are posed here, yet the answer to these and others that seems to have eluded most of us is that the messaging to the general population has failed. 

The pink breast cancer ribbon captured the imagination of both the health care community and the general population. As a result of self-examinations and “buddy checks,” vast improvements have been made in the research, treatment and most importantly, prevention of breast cancer. Education is empowering, and teaching individuals how to become their own health care advocates is part of the equation for success. Information is important, but changing behaviors is the essential if progress is to be made.

We have numerous medical and academic societies in the wound care and vascular specialties whose collective focus is noble, but what happens after the meetings end? The disconnect between the health care community and the public must become a key part of the focus if our efforts are to have the widespread impact that is needed. The public has little concept of what is at stake regarding chronic wounds and amputation, and ways to become proactive in their own care have not been adequately delivered.

The SALSAL Plan

As the problems we are all working against are multifaceted, 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 is stand alone at first inspection, all are related and designed to further increase awareness as well as being 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 event was held in November 2020. Screening populations at elevated risk for diabetes, PAD, and amputation has proven to be successful, not only in identifying previously undiagnosed and now suspected pathology, but in getting such people to the appropriate providers in their respective communities. Among conditions that have resulted in referrals during SALSAL Community screening events are PAD, congestive heart failure, neuropathy and even one person who was discovered to have detached retinas. Additional events are being planned for 2023 and beyond with the most recent event having been held in San Antonio a few weeks ago.

·      The White Sock Campaign was created to not only draw attention to the lower extremities, but to also create teaching 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 way. What began as a way to create awareness of PAD during September—which is PAD awareness month—through the use of single white socks and social media, has spread to a year-round phenomenon with participants posting photos from countries all over the world!

·      The Harold L. Johnson Memorial Scholarship was created to assist and encourage wound care providers who may be facing economic barriers, into taking board certification examinations administer through the American Board of Wound Management. The scholarship gives preference to veterans, as Harold Johnson was a Viet Nam veteran, whose greatest fight was against diabetes and renal disease, and was himself a double amputee. 

·      The patient assistance program was established to provide those in need with items essential for healing or to prevent wound recurrence. Wound supplies, diabetic shoes, socks, walkers, Roll-A-Bout walkers and canes are some of the items that have been distributed to individuals and other entities through SALSAL. 

·      Hurricane Dorian relief to the Bahamas was one other method to raise awareness while supplying community outreach. Nassau, Bahamas residents were devastated by Hurricane Dorian during 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 Clear

To summarize, the Save a Leg, Save a Life Foundation has been built on 3 key principles. Those are, and remain, Education (of both the medical community and the general population), Advocacy, and Community Outreach.

Emphasizing the importance of amputation prevention and advanced wound care can no longer be restricted to the medical community. If the general population understood the realities of chronic wounds and amputations from a wound care provider’s 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.

The Save a Leg, Save a Life Foundation has resonated among many to date, but our target audience is much greater than we have reached so far. Our mission is driven by the love of our patients and the desire to end often unnecessary suffering.

SALSAL FAQ

1.    How can I join a chapter? We do not have chapters and do not plan on using this model in the future.

2.    How did you come up with the name SALSAL? I wrote the term, “save a leg, save a life” on a napkin one evening in 2004 when I was preparing a PowerPoint presentation while simultaneously drinking a cold beer. “I have to do something with this,” I thought, and subsequently, the term was used to name the lunch and learn group that had grown into the “Wound Care Consortium of Jacksonville.” 

3.    What does SALSAL mean? The term “Save a Leg, Save a Life” not only refers to lower extremities and amputation prevention, but connects related conditions such as coronary artery disease, peripheral arterial disease, renal disease, heart attack and stroke. Cardiac events such as myocardial infarction and stroke can sometimes be prevented through vascular screening of the lower extremities.

4.    How is the SALSAL Foundation organized? As a non-profit organization, we have a Board of Directors (and no shareholders). We report to the public and have no paid employees. We hold monthly board meetings and follow bylaws which were created at the time of incorporation (State of Florida). Federal Tax ID # is 32-0467696.

5.    Who are your board members? Our current board is comprised of Desmond Bell, Tracey Paulfrey, Frank Aviles, Carol Barry, Mark Melin and Karl Hindle. 

6.    How can I get involved? Many ways, including participation in the “White Sock Campaign” (#WhiteSockCampaign). Donations are tax deductible and may be made via our website. You can also designate The Save a Leg, Save a Life Foundation as your charity of choice through Amazon Smile and portions of items purchased through the site will be donated by Amazon to SALSAL.

7.    Where will the next community outreach events be held? Plans are presently underway for Ft. Worth, Miami, Flagstaff, Buffalo and at least one additional site during 2023. We are also working with the Ministry of Health in Trinidad and Tobago on an even there to address wound and amputation issues throughout the Caribbean.
 
Dr. Bell is an Executive Physician Coach for MD Coaches LLC and is a Certified Wound Specialist. He is Chief Medical Officer for Omeza, Founder and President of the Save A Leg, Save A Life Foundation, and a Fellow of the Royal College of Physicians and Surgeons of Glasgow.
 
References
1. Centers for Disease Control and Prevention. National Diabetes/basics. Feb. 2021.  
2. Geiss LS, Yanfeng L, et al. Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care. 2019 Jan; 42(1):50–54