Repeating first year as career changer

OP, I appreciate that you are trying to be optimistic and make the best out of a bad situation. You need to have a more realistic outlook and be absolutely sure that you'd be ok with an outcome other than the ones you described. Failing a semester is a big deal and scoring 250 on step 1 is extremely hard as is honoring rotations. Again it's fine that you're optimistic but going from bottom 5% of your DO class to top ~15% of all step 1 test takers is far from likely.

The easiest route of the ones you described is anesthesia. The field's popularity is plummeting among US MDs which has opened it up to DOs and IMGs. You can end up at a solid program as a DO even with a red flag on your record. Realize though that the job market is pretty tight now with the encroachment of CRNAs and hospitals looking to cut costs.

EM and IM are both moderately competitive specialties that are getting more popular. I can't really comment about your chances in EM but the chance of ending up at an academic IM program after failing the first semester are very low. Only the cream of the crop DO IM applicants nationwide end up at the mid-tier academic programs that accept DOs. You're likely already out of the running for those spots. A handful more end up at low-tier programs, usually in less desirable locations. The vast majority end up at community programs. You can look up your school's match list or those of other DO schools to verify this and I'd be happy to help you interpret them if you want. I would guess that failing a semester will make it a very uphill battle with regards to getting into an academic IM program. This will be a big obstacle for matching heme/onc or pulm/CC, two of the top 4 subspecialties in terms of competition. This year only 4% of heme/onc and 8% of pulm/CC spots went to DOs. My point is that if you do end up applying IM you have to be at peace with being a hospitalist or PCP at the end of residency. You're still a long way off from making this decision though.

Good luck.

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Repeating first year as career changer