Why do you believe public awareness regarding peripheral arterial disease (PAD) has not increased at the same rate as other conditions?

First and foremost, there seems to be a fundamental lack of understanding of PAD among health care providers. This lack of comprehension, especially regarding such issues as the relative 5-year mortality rates for PAD compared to other diseases, such as breast and prostate cancer, translates into a lack of urgency when it comes to screening and referring patients to endovascular specialists. Primary care physicians, for example, have not really gotten the message regarding PAD, and therefore, there is little information disseminated to patients at this level.

When the words pink and ribbon are juxtaposed, we have become conditioned to think about breast cancer awareness. In October, the color pink will be everywhere, from NFL team uniform accessories to newspapers being printed on pink paper. This is a reflection on a tremendous marketing campaign that has permeated the psyche and consciousness well beyond the United States. Yet in my travels speaking to providers and patients within our Save A Leg, Save A Life (SALSAL) chapters across the country, most people have no idea that September is PAD Awareness month. There is no official PAD Awareness ribbon.

There has not been a grassroots campaign that has targeted the public when it comes to PAD awareness. I find it fascinating that within the wound care and endovascular communities, there are many talented people who know the serious and far-reaching impact of PAD, but no one has been able to get everyone on the same page when it comes to spreading the word.

Part of our mission within SALSAL is to connect the dots between conditions such as diabetic foot ulcers, PAD, heart attack, and stroke, as well as amputation prevention. We use a grassroots approach, and we are determined to make Save A Leg, Save A Life into a household term, in much the same way that the Komen Foundation has made the pink ribbon synonymous with breast cancer. We are about ready to unveil our PAD Awareness ribbon!

What do you feel is the role of the podiatrist in increasing public awareness about PAD? The role of the interventionist?

Podiatrists are truly the front line in terms of PAD recognition because our focus is on the lower extremities, feet, and toes. When it comes to increasing public awareness, our role goes beyond the walls of our offices, hospitals, and clinics. There has been an ongoing campaign by the American Podiatric Medical Association to encourage patients to take their shoes and socks off when visiting their primary caregivers, especially if they are diabetic or have a history of PAD. One of my recurring frustrations as a podiatrist specializing in wound care and limb preservation has been on the occasions when a patient presents with a foot or leg ulcer and upon questioning, I learn that he or she has recently been to a primary caregiver. That provider never noticed or looked at the patient's lower extremity and cost us valuable time that could mean the difference between a favorable outcome versus an amputation.

As for the role of the interventionists, once again, the public is lacking in general awareness of not only the technology that is saving legs and lives, but of the disease itself. The breakthroughs of the last 10 years are simply incredible, yet the public is generally unaware that the same skill set that can be utilized to open occluded cardiac vessels is helping heal wounds and prevent amputations. In my opinion, interventionists need to create excitement about their skills and technology, through not only education but also marketing to the public.

Over the last several years, when speaking to audiences composed of laypersons, I ask, “By show of hands, who has heard of PAD?” Usually, a few hands will go up, but the majority do not. The next question I ask to those who raise their hands is, “Do you know what PAD is?” To which, the most common answer I get is “Restless leg syndrome.” In my years of speaking on the topic, I have had only one person answer the question half correctly. This speaks volumes.

What can interventionists and podiatrists uniquely bring to the table, and how can they work together to promote common goals?

It is extremely encouraging to see podiatrists and interventionists working together. When I was in school, I never would have imagined that the specialist who I would work most closely with one day would be a cardiologist. I had never heard the term interventionist until about 6 years into my practice!

Each specialty brings a different skillset, but the holistic approach to the patient through open communication intuitively produces better outcomes and better management of the patients overall. As my dear friend and colleague, interventional cardiologist, Yazan Khatib, MD, once said to me, “You guys are the carpenters; we are the plumbers.”

In our practice, we make frequent referrals to interventionists. Time and time again, I have sent patients to Dr. Khatib due to concerns of significant PAD as a cause of a nonhealing ulcer, only to have him call me to tell me that while the patient needs lower extremity intervention, he discovered cardiac vessels or carotids that needed to be addressed first. It can be satisfying to learn that the referral to my interventionist colleague may have prevented a catastrophic heart attack or stroke.

What are the ideal roles of podiatrists and wound care specialists in the continuum of a critical limb ischemia patient's care?

Recognition of the PAD or critical limb ischemia patient is the first and most obvious role of the podiatrist and other wound specialists, or even primary caregivers. It is what happens after that can make a huge difference. The continuum of care is so important to the long-term well-being of our patients and is best achieved through diligent short-term reassessment. In other words, our job does not end after the referral is made to an interventionist. In reality, our job is just beginning, as it is during the follow-up after interventional procedures have been performed when our skills come into play. We know that these patients have the risk of reocclusion. However, they are “medical time bombs,” and their multisegmental disease coupled with their typical overall poor health means we must be constantly watching for signs of vascular shutdown to the lower extremities, as well as other warning signs of exacerbation of their vascular disease. At the first sign of any concern, we call our interventionists. We are their postprocedure eyes and ears.

What initially led you to become more involved in your patients' interventional courses? Did you approach interventional colleagues, or vice versa?

My practice is not the typical podiatric practice, as we have specialized in wound care and limb preservation for the past 12 years or more. We do not treat general podiatric concerns, as I love helping patients through the devastating issues surrounding life with chronic wounds.

That said, the first 6 years of my practice were filled with trial and error in finding the right vascular specialists for my patients; I tried working with a number of them.

It was a local rep for one of the interventional device companies who had the foresight to introduce me to Dr. Khatib. That was a pivotal moment because not only did we immediately connect, but we have since become close friends and cofounders of the Save A Leg, Save A Life Foundation. This is also an example of how a great industry rep is worth his or her weight in gold. When I think of how many lives have been previously and potentially touched because of that introduction, it makes me wonder if fate stepped in, or if some other force was at work. Regardless, thank you Jen Cart (now with Covidien, Mansfield, MA)! You will always be an unsung hero, and credit must be given where it is due!

What advice would you offer interventionists about how to establish closer ties with nearby podiatrists and wound care specialists?

At the risk of self-promotion, I would highly recommend becoming involved in a local chapter of SALSAL. If a chapter does not exist in your area, contact us, and we will help you in the process of organizing one. Otherwise, we can help you connect with an existing chapter.

SALSAL is a community effort that began as a way to bring like-minded providers together. We share a passion for limb preservation. The concept is really quite simple in that by bringing people together periodically, we can develop relationships that will facilitate better care. When politics are put aside, and relationships are developed between providers within a community, people not only know who to turn to for help but are also more likely to ask for help.

What are the goals and purposes of the Save A Leg, Save A Life Foundation?

SALSAL has been built on three principles. They are education of providers and the public, community outreach and intervention, and advocacy.

Our mission statement really sums things up. We were founded to reduce the number of lower extremity amputations and to improve the quality of care for our fellow citizens who are afflicted with wounds and complications from diabetes and PAD.

We are a nonprofit foundation, and our members and staff are volunteers. Among our goals is to achieve at least a 25% reduction in lower extremity amputation rates in communities where we have established chapters. We call this our Drive for 25.

Our next step is to increase awareness of PAD in both primary care providers and the public. This past May, I began broadcasting a radio program in Jacksonville that airs every Sunday. The SALSAL radio program on WOKV (690 AM/106.5 FM) features discussions and interviews that pertain to limb preservation, wound healing, and everything in between. We are attempting to reach the public through radio as a way to drive the demand for greater utilization of interventional procedures and advanced evidence-based wound care. We believe that the public will help us raise the bar. I cannot imagine that once the public better understands the terrible consequences of PAD and amputation, that they will accept the present state and subjective nature of amputation.

We are also increasing our use of social media to reach beyond the medical community. Our website continues to evolve as a portal for both provider and public education.

We must also put a face to this disease. The term PAD doesn't necessarily register with the majority of the public, and statistics may be meaningless to them, as well. Part of our strategy is to educate the public and providers by linking the disease to people they know as loved ones and neighbors, through their stories of living with PAD, as an amputee, or as someone who has been spared the loss of a leg due to timely intervention.

Desmond Bell, DPM, CWS, is founder of the Limb Salvage Institute/Wound Care on Wheels, LLC, in Jacksonville, Florida. He is also the cofounder of SALSAL (savealegsavealife.org). Dr. Bell has disclosed that he is a speaker for Organogenesis, Cook, and Cordis' PAD series and webinar, and is involved with video web projects for Medscape and theheart.org. He may be reached at (904) 642-0877; drbell@savealegsavealife.org.