Evaluating Facial Trauma in the Amish: A Study of a Unique Patient Population

Abstract

Study Design: Retrospective Chart Review. Objective: The lifestyle of the Amish exposes them to unique mechanisms of injury, making them an important patient population from a facial trauma standpoint. This study analyzes the demographic and clinical risk factors of facial trauma in the Amish. Methods: This retrospective chart review identified all Amish patients presenting with facial trauma at a single institution between 2013–2023. Results: There were 87 Amish facial trauma patients. The median age was 9 years old, and 67.8% were male. Most injuries occurred on the road (41.4%), farm (28.7%), or at home (25.3%). The most frequent mechanisms were buggies (27.6%), falls (26.4%), and animals (18.4%). Fifty-eight patients sustained facial fractures, with orbital (n = 40), maxillary (n = 25), and nasal (n = 19) fractures being the most prevalent. The most common cause of facial fractures was buggy injuries (n = 17). Facial reconstruction was performed in 54.2% of buggy injuries, 31.3% of animal injuries, and 8.7% of falls. Patients with buggy injuries presented with the lowest Glasgow Coma Scale (GCS) scores (median 13.5) and had the longest inpatient hospital stay (median 3 days). Conclusions: Increased injury prevention efforts, especially towards buggy injuries, are necessary.

Introduction

The Amish are descendants of the Swiss/German Anabaptists who first immigrated to the United States (US) in the 1700s. Since then, the Amish population has become a rapidly growing rural population in the United States [1]. Pennsylvania, followed by Ohio, and Indiana, have the highest concentrations of Amish populations with Lancaster County, Pennsylvania, being home to the largest Amish settlement in the U.S. The Amish tend to follow a very simple lifestyle and generally eschew most modern technology, work in traditional industries (e.g., farming, woodworking, and manufacturing), and travel by nonmotorized means [2].

Their way of life makes them susceptible to unique mechanisms of injury, making them an important patient population from a facial trauma standpoint. Facial trauma may be severe and disabling, and injuries are often preventable. Few studies have investigated mechanisms of trauma in this population, but less is known about facial trauma in the Amish population specifically [3,4,5]. This study aimed to analyze demographic and clinical risk factors for facial trauma in the Amish population seen at a tertiary level 1 trauma center in Central Pennsylvania.

Materials and Methods

A retrospective chart review of Amish patients of all ages presenting with facial trauma at the Penn State Milton S. Hershey Medical Center between 2013 and 2023 was performed. Amish patients were identified by filtering patients with the designation “Amish” under religion in the electronic health record. Descriptive statistics were used to summarize the data including patient sex, age at facial trauma, mechanism of facial injury, location of the injury, Glasgow Coma Scale (GCS) score, type of injury sustained, concomitant skull fractures, intracranial injuries, other injuries sustained (abdominal, orthopedic, or cardiopulmonary injuries), surgical treatment if received, discharge disposition, and status at discharge (alive or deceased). Comparisons of these measures among the most common mechanisms of facial trauma were performed using Kruskal-Wallis, Chi-square, and Fisher’s exact tests. Bivariate analysis of potential predictors of increased length of stay (≥2 days) were evaluated using Kruskal-Wallis and Chi-square tests. Factors with P < .05 were evaluated further in multivariable logistic regression models to determine the most significant predictors of having an increased length of stay. Significance was defined as P < .05, and all analyses were performed using SAS statistical software version 9.4 (SAS Institute Inc., Cary NC). This study was approved by the Institutional Review Board of the Pennsylvania State University (STUDY00023138).

Results

A total of 87 Amish facial trauma patients were identified. The median age was 9.0 (0-65) years, and 67.8% (n = 59/87) were male. The locations of injury were on the road (n = 36/87, 41.4%), farm (n = 25/87, 28.7%), home (n = 22/87, 25.3%), sports game (n = 2, 2.3%), and other (n = 2, 2.3%). The most common mechanisms of facial trauma were buggies (n = 24, 27.6%), falls (n = 23, 26.4%), and animals (n = 16, 18.4%; Figure 1). Over a third of patients had concomitant intracranial injuries (n = 33/87, 37.9%) or skull fractures (n = 33/87, 37.9%). Loss of consciousness (LOC) was reported in thirty-two patients (36.8%). On discharge, four patients were discharged to rehab (4.5%), 81 to home (93.1%), and two patients died from trauma (2.3%).

Fifty-eight patients sustained facial fractures, with orbital (n = 40), maxillary (n = 25), and nasal (n = 19) fractures being the most prevalent. The most common causes of facial fractures were buggy injuries (27.6%, n = 16/58, falls (25.9%, n = 15/58), and animal injuries (17.2%, n = 10/58). Facial reconstructive surgery was performed in 13/24 buggy injury (54.2%), 2/23 falls (8.7%), and 5/16 (31.3%) animal injury patients (P = .003). Besides facial fractures, other types of facial trauma included facial lacerations (n = 32), abrasions (n = 17), ecchymosis (n = 14), and emphysema (n = 3).

Patients with buggy injuries presented with the lowest GCS scores (median 13.5) and had the longest inpatient hospital stay (median 3 days). Of those with buggy injuries, over half presented with skull fractures and intracranial injuries, and over a third also had orthopedic injuries. Approximately a third of patients also had skull fractures or intracranial injuries. Three patients also had skull fractures, and four had intracranial injuries. Patients’ clinical features based on the top 3 mechanisms of injury and types of facial fractures sustained overall can be found in

Table 1. Clinical Features Based on the Top 3 Mechanisms of Injury.

and

Table 2. Fractures Sustained by Amish Facial Trauma Patients.

.

Bivariate analysis showed that significant predictors of having an increased length of stay (≥2 days) were the mechanisms of injury, location of trauma, lower GCS score, LOC, skull fracture, intracranial injury, facial fractures, facial laceration, and having other concomitant injuries. (

Table 3. Bivariate Analysis of Predictors of Increased Length of Stay (≥2 days).

) When these factors were evaluated simultaneously in a multivariable logistic regression model to determine the most important factors, the final model indicated that with adjustment for GCS, the odds of having an increased length of stay were 21.8 times greater for those with intracranial injuries (95%CI 4.81-98.62, P < .001), and 7.5 times greater for those with other injuries (cardiopulmonary, orthopedic, or abdominal injuries) (95% CI 2.05-27.11, P = .002) (

Table 4. Multivariable Logistic Regression Model of Significant Predictors of Increased Length of Stay (≥2 days).

).

Discussion

This study analyzed the common causes and subsequent treatment of facial trauma in the Amish population. Although research has explored variations in trauma between urban and rural populations, the Amish are a diverse, rapidly growing rural population with traditions that set them apart from the general population [6]. A lifestyle emphasizing simplicity is seen in the lack of modern technologies, including electricity, telephones, central heating, and automobiles [7]. Many Amish are also farmers, although some may work in other traditional jobs such as carpentry, putting them at increased risk of performing potentially dangerous tasks [8]. The unique aspects of an Amish lifestyle make them a unique and vulnerable population from a facial trauma standpoint. Very different from the general population, our study found that the most common mechanisms of facial injury were buggy accidents, falls, and animal-related injuries, with 54.2% of buggy injuries, 8.7% of falls, and 31.3% of animal injuries requiring facial reconstructive surgery.

In our study, most patients were male, which is consistent with the literature reporting higher rates of trauma in males [9,10]. Buggy injuries and falls were the most common causes of facial injury overall and were responsible for the majority of facial fractures. Studies assessing all types of trauma in both the Amish and general population report that falls are the most common cause [3,5,11]. The high rate of trauma and facial fractures due to buggy injuries may explain the high rate of concomitant intracranial injuries and skull fractures. Vehicular trauma is one of the leading causes of facial trauma, and traumatic brain injury is often associated with maxillofacial injury [12,14]. Buggies are wide horse-drawn carriages, typically grey or black, that can be either open or enclosed. They remain a primary mode of transport for the Amish but share the road with modern motorized vehicles, without a separate buggy lane. Buggies lack general safety features such as seatbelts and airbags and move at 5-8 miles per hour (mph) compared to a standard car that drives at 40-50 mile/h, increasing the risk of severe collision injuries to those in buggies [15]. One study found that a person in a buggy is three times more likely to have an injury than someone in a motorized vehicle [16].

Of interest, four out of five patients in our study who suffered a passenger-related motor vehicle accident were between 16 and 20 years of age. While most Amish adhere to traditional religious and cultural practices where motorized vehicles are not used, Rumspringa is a time in the Amish community where youth may experience life outside the community in the modern world. This may explain why some causes of facial fractures were due to being passengers in motor vehicles. Alternatively, for transportation, some Amish communities allow people to ride in cars if driven by non-Amish people for example for work or medical appointments, or it is also possible that these were Amish patients who elected to live a more modernized lifestyle.

After the road, the second most common location of facial trauma in our cohort occurred on a farm. Consistent with cultural and religious beliefs, the Amish live in an agrarian society [17]. However, agriculture can be a dangerous occupation, with animal and farm machine-related injuries making up over 10% of trauma cases in the Amish community [4,5]. Also, children often participate in farm work at a young age and may not adequately understand safety practices and injury prevention [8]. A study of farm-related injuries in pediatric patients reported that 38.5% had machinery-related injuries, and 40% had animal-related injuries [18]. The farm is more often a place of work rather than play for the Amish, as 49% of pediatric farm injuries occur while the child is working [19].

A prior study assessed patients with facial fractures and concomitant injuries and found orbital fractures to be the most prevalent type of fracture, which were also the most common in our study [14]. In our cohort, over a third of patients had either concomitant skull fractures, intracranial injuries, and abdominal, orthopedic, or cardiopulmonary injuries. Injury severity may also increase the likelihood of Amish patients deciding to seek care, leading to a high proportion of buggy injury patients in our study. These patients had the lowest average GCS scores and many sustained facial fractures that required surgery. Those with less severe injuries may not have sought care for their injury or may have presented to a less acute care setting such as a physician closer to their community, an urgent care facility, or a local non-level 1 trauma center.

The Amish primarily reside in rural settlements where there is a disproportionate lack of healthcare services [1,20]. To tackle these issues, it is important to understand how the Amish population interacts with the modern healthcare system. Most will receive medical care if it aligns with their health beliefs and practices. Amish often use local doctors and dentists and only visit specialists and hospitals if necessary. Many prefer healthcare from someone known and trusted by the Amish community [21]. Lack of technology and distance from larger medical centers may make receiving care more difficult and costlier. Furthermore, Amish patients’ primary language may not be English, and common languages include German, Swiss, and Pennsylvania Dutch [8].

Since life is centered around the home or farm, home health interventions and visits are preferable to outside institutions. For example, hay holes, openings on the second floor of barns used to drop feed to animals below, are common causes of falls in Amish children. The Anabaptist Youth Trauma Prevention Consortium distributed hay hole covers, which led to a 50% decrease in falls and facial fractures from hay hole falls in Pennsylvania [22]. This emphasizes the importance of simple, effective interventions aligned with Amish culture. Furthermore, hay hole covers cost approximately $100 compared to a hospital stay for facial trauma, which can cost thousands of dollars. Amish safety committees and farm safety days have been developed to partner Amish residents with medical and legal personnel to identify common hazards and determine best practices for change. In northeast Ohio, home to another large Amish settlement, the Department of Transportation identified routes with high buggy traffic concerns based on feedback from Amish community meetings and surveys and provided grants to widen roads, create buggy lanes, and install buggy detectors [15]. With an understanding of the causes of facial trauma, we can better develop community based interventions in line with Amish culture that patients are also more likely to comply with.

Addressing facial trauma is also essential because most Amish are self-pay, where families and communities pool money to help cover costs. The Amish are exempt from the Affordable Care Act, and many do not participate in or receive social security benefits or Medicare [23,24]. A study of facial fracture patients who presented to the emergency department reported that the average charge per visit was $3912 [25]. Studies of orbital fractures report that the mean charge per visit can be as high as $8000 and that surgical repair is associated with over $22,000 in hospital charges [26,27]. In our study patients with intracranial injuries and other non-facial injuries were 21.8 and 7.5 times more likely to have an increased length of stay, respectively. Severe facial trauma, especially those with other concomitant injuries, may require extensive multidisciplinary care and have debilitating short and long-term consequences. Given the distinct cultural and social aspects of Amish life, it is important to understand the unique mechanisms of facial trauma, which can inform culture-focused care in this patient population which includes instilling low-cost interventions that align with the Amish way of life.

The Penn State Milton S. Hershey Medical Center is located in Central Pennsylvania and has a high proportion of Amish patients due to its proximity to Lancaster County, home to the largest Amish settlement in the US. However, as a level 1 trauma center, our institution may see more high-acuity injuries than community hospitals or clinics. Another limitation is the relatively small sample size of our Amish facial trauma population, so studies assessing facial trauma at hospitals near other Amish settlements across the country may be more representative of the true population. Larger studies may also delineate the most common causes of facial trauma by age group.

Conclusion

Amish patients are susceptible to unique causes of facial trauma compared to the general population. Increased injury prevention efforts, especially towards buggy injuries, are necessary.

By understanding the unique causes of trauma and lifestyle factors associated with facial trauma, one can provide culturally responsive care and guide specific trauma prevention efforts in this unique patient population.