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It’s been a long time since Sam’s been knocked unconscious, but the painful, nauseous confusion when he comes around is very familiar. The shifter is right there, of course, still wearing its Dean costume. A backhand across Sam's throbbing jaw does nothing to help his brain come back on line, but long honed survival instincts kick in before he can sink under again. Beneath the shifter's deranged monolog, it’s quiet in the room the way it wouldn’t be if Dean was here. Here and awake. Here and alive. The shifter doesn't kill those it impersonates. Sam hangs on to that.